Talk:Gender dysphoria/Archive 8

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possible statement on effectiveness of biological treatment, copyright question

Hi all, continuing the discussion from above about quality of evidence (which got too long), here is a proposed addition, which adds two recent evidence reviews to that earlier discussion. This is in "talk" because, for instance, the first sentence is a direct quote, but all the words mean something specific--"indicate" is different than "suggest", which appears to be a technical statement. Is this ok, as it appears in quotation marks, or is there another way to deal with copyright issues?

“Most available evidence indicating positive outcomes for gender reassignment is of poor quality.”[19] More rigorous evaluations are needed to assess endocrine and surgical protocol effectiveness and safety.[20] For instance, a 2020 Cochrane review [21] found insufficient evidence to determine whether feminizing hormones were safe or effective (there has not been a similar review for masculinizing hormones); more research is needed to understand the potential harm of hormonal therapies [20]. For surgery, studies are needed to examine the long-term psychological benefits (several have found significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality [22] in one of the few studies with robust methodology[19]).

with references:

[1]“Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide.”

[2]“In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); [...] and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”“Future research is needed to ascertain the potential harm of hormonal therapies (176).” “Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).” "We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.”

[3]"We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition."

[4] "In a nationwide long-term follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted as elevated after juridical and medical SR."

Thoughts? Thanks. Jdbrook (talk) 13:55, 31 March 2021 (UTC)

@Kaldari: I see you have changed these insertions, in particular, you noted that the claim about the evidence being poor was: "This is the opinion of one researcher, not an actual medical review or systematic meta-analysis. Also trimming sentence on surgery so that it is concise and neutral, rather than over-emphasizing risks."

Please explain why your changes now make the entry "neutral", and why the previous ones were over-emphasizing the risks? What criteria are you using to determine that the earlier description (above) was "over" emphasizing the risks?

Several references find that the evidence is lacking or low quality.

Three references talked about long term pathology and/or suicides that have been seen, all of which were reviews. This information has been taken out, claiming DUE.

Here is one removed phrase:

(several have found significant long-term post-surgery psychological and psychiatric pathology,(ref) persistence of suicide attempts and suicide mortality (ref) were found in one of the few studies with robust methodology(ref)).

The exact wording in the Endocrine Society Guidelines had been provided in the reference itself, as discussed in this page, immediately above, but that has also been removed. Your reason for not quoting the major concerns listed in the source, the direct quotation in the reference, is "medical jargon" and WP:COPYQUOTE. This is the reference:

Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); [...] and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”“Future research is needed to ascertain the potential harm of hormonal therapies (176).” “Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).” "We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.”

I do not see why discarding all of this information better represents the state of knowledge as reported in the literature. Several references are finding the same dangers. And there are more emphasizing insufficient evidence, e.g. Hembree et al 2017 quote another paper for one thing that they say has good outcomes, but that paper [5] says:

The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.

Also, UK NICE just completed two major evidence reviews [6] , [7] and both found

“The critical outcomes for decision making are impact on gender dysphoria, impact on mental health and quality of life. The quality of evidence for all these outcomes was assessed as very low certainty using modified GRADE.”

Again, "low quality certainty."

To summarize, several authoritative reviews note harmful outcomes (suicide is explicitly mentioned in two of them) and that the evidence is low quality, low quality certainty, poor, etc.. Many list the reasons. The reference itself gave the quotation from the article which you took out. This is what the research literature says. Please explain why putting in this information from the literature about dangers and uncertainties is DUE, i.e., why it is "over-emphasizing risks", and why is leaving it out is "neutral". And why giving the detailed quotation for clarification is "medical jargon" and COPYQUOTE.

Also, what do you do mean by "an actual medical review"?

Thanks. Jdbrook talk 14:59, 22 April 2021 (UTC)

In medical literature there is a hugely significant difference between "low quality" evidence (or even "very low quality" evidence) and "lacking" evidence. From your comments above, I'm not sure if you understand that. There are 4 levels of evidence quality in the GRADE system: high, moderate, low, and very low. These basically translate as follows:

High: Well-performed randomized, controlled trials

Moderate: Randomized, controlled trials with important limitations

Low: Observational studies or unsystematic clinical experience

Very low: Observational studies with significant flaws or inconsistent clinical experience

There are huge swaths of medical practice that are based on "low quality" evidence, and in many cases, including GD, it is difficult or impossible to generate high quality evidence due to ethical considerations. For example, it would be unethical to deny medical treatment to a person with GD in order to create a control group for a study. Thus there will likely never be "high quality" evidence for medical GD treatment, regardless of how effective it might be. The reason why my changes make the text more neutral is because it isn't neutral to only discuss in detail the risks and negative outcomes without dicussion of the benefits and positive outcomes. Otherwise we are cherry-picking what we are presenting to the reader and presenting a biased point of view. Kaldari (talk) 02:49, 23 April 2021 (UTC)

By "actual medical review" I mean a paper that is classified as a "review", "systematic review", or "meta-analysis" by PubMed. "Psychiatry's ethical involvement in gender-affirming care" is not classified as any of those and is essentially an opinion piece by a single psychiatrist. Kaldari (talk) 02:55, 23 April 2021 (UTC)

@Kaldari: Thank you for explaining what you mean about evidence and how you define review.

As far as neutral, I believe your core statement is:

it isn't neutral to only discuss in detail the risks and negative outcomes without dicussion of the benefits and positive outcomes.

The benefits and positive outcomes you want to include are of "very low certainty" for people under 18 (and low quality or worse, GRADE).

Significant risks have been found, and long term physical and mental outcomes and risks are not known.

These are what the literature says.

I think you are arguing that "very low quality" is the best possible because you believe controls are unethical for this case, and so that these qualifiers and specific dangers should not be reported in Wikipedia. This appears to be your interpretation of why parts of the literature should be discarded. Why is this neutral rather than your POV?

Discussing your interpretation further in a side comment, as Wikipedia inclusions should not depend on what we personally think medical research should be doing or not doing or why:

"in many cases, including GD, it is difficult or impossible to generate high quality evidence due to ethical considerations. For example, it would be unethical to deny medical treatment to a person with GD in order to create a control group for a study."

1.You are giving GD as an example of something you are claiming is standard practice, in order to justify treating GD this way. This is circular.

2.There are studies of GD treatments with controls.

3.As it has not been shown reliably that medicalization helps, that is what "very low certainty" for positive mental health outcomes means, this means that medicalizing only some people, i.e. having controls, is not unethical.

Controls are especially possible since there are many treatment pathways for GD, medicalization is not the only one. One review also noted that comparative studies should be done. This is all a side comment, as I don't see that convincing you personally that controls are ethical should in any way be determining whether the quality of the mental health outcomes or the dangers for treatment should be included in the page.

Lastly, why did you remove the detailed quotation in the literature reference? I looked at COPYQUOTE, what exactly is the issue?

Thanks. Jdbrook talk 12:49, 23 April 2021 (UTC)

Hi, Jdbrook. I'm afraid I haven't been following this whole discussion as closely as I might, but what is the quality of evidence for your assertion that Significant risks have been found for patients under 18? Thanks. Newimpartial (talk) 13:37, 23 April 2021 (UTC)

@Newimpartial: Hi, thank you for joining in. I am not aware that I asserted significant risks have been found for under 18s. (The under 18 comment is about evidence for mental health outcomes in the NICE review for under 18s, to illustrate that the mental health outcome uncertainty is not POV.)

The statement which was modified, which I asked Kaldari about, is at top of this section.

“Most available evidence indicating positive outcomes for gender reassignment is of poor quality.”[19] More rigorous evaluations are needed to assess endocrine and surgical protocol effectiveness and safety.[20] For instance, a 2020 Cochrane review [21] found insufficient evidence to determine whether feminizing hormones were safe or effective (there has not been a similar review for masculinizing hormones); more research is needed to understand the potential harm of hormonal therapies [20]. For surgery, studies are needed to examine the long-term psychological benefits (several have found significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality [22] in one of the few studies with robust methodology[19]).

Plus his removal of the detailed reference quotation showing about exactly what is claimed to be known or not known. Also at top of this section.

Thanks. Jdbrook talk 00:00, 24 April 2021 (UTC)

So what did you mean by Significant risks have been found and long term physical and mental outcomes and risks are not known[8] (emphasis added)? Thanks. Newimpartial (talk) 00:14, 24 April 2021 (UTC)

Hi-thank you. I was referring to the statement in the above which was removed and which I think should be in there:

(several have found significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality [22] in one of the few studies with robust methodology[19]).

More details about risks and unknowns were in the citation, again which has been removed by citing COPYQUOTE, which I am also asking about.

Here is the original insertion (from above, as I put it in talk before putting it on the page). I have removed the sentence from (19), and the phrase about the robustness of the study finding suicides which also quotes (19).

“More rigorous evaluations are needed to assess endocrine and surgical protocol effectiveness and safety.[20] For instance, a 2020 Cochrane review [21] found insufficient evidence to determine whether feminizing hormones were safe or effective (there has not been a similar review for masculinizing hormones); more research is needed to understand the potential harm of hormonal therapies [20]. For surgery, studies are needed to examine the long-term psychological benefits (several have found significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality [22]).

with references, currently the quotations are gone (I have put in boldface the parts relevant for "long term physical and mental outcomes and risks are not known"):

[9]“In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); [...] and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”“Future research is needed to ascertain the potential harm of hormonal therapies (176).” “Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).” "We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.”

[10]"We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition."

[11] "In a nationwide long-term follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted as elevated after juridical and medical SR."

The information about the current level of understanding could be, instead of starting with (19), as that does not seem to be considered a review, a NICE evidence review from the UK:

The quality of evidence for mental health, quality of life and gender dysphoria outcomes (for under 18s), for puberty blockers and hormones, was found to be very low certainty.

with reference: [12] and [13] “The critical outcomes for decision making are the impact on gender dysphoria, mental health and quality of life. The quality of evidence for these outcomes was assessed as very low certainty using modified GRADE.”

The phrasing as it currently stands has no reference to the significant harm (e.g. suicide) which has been reported, or the issues with evidence for anything but m to f hormones. This appears to be a problem with POV. Thanks. Jdbrook talk 03:59, 24 April 2021 (UTC)

Unless I missed something, the only reference to risks in the sources you just cited observe that the risks are not known and call for a careful assessment of the ... risks and benefits. Neither source supports your assertion above that Significant risks have been found, so I was wondering what your source was, and what quality of evidence supported that assertion? Thanks. Newimpartial (talk) 14:23, 24 April 2021 (UTC)

Hi @Newimpartial:, thank you. The proposed insertion is the original insertion, at the top of this section, with a modification, following the advice of @Kaldari:. That is, the link to what is now ref 20 is added, the old ref 19 is taken out (19 now refers to the old 20).

More rigorous evaluations are needed to assess endocrine and surgical protocol effectiveness and safety.[19] The quality of evidence for mental health, quality of life and gender dysphoria outcomes (for under 18s), for puberty blockers and hormones, was found to be very low certainty[20], and, for instance, a 2020 Cochrane review [21] found insufficient evidence to determine whether feminizing hormones were safe or effective (there has not been a similar review for masculinizing hormones); more research is needed to understand the potential harm of hormonal therapies [19]. For surgery, studies are needed to examine the long-term psychological benefits (several have found significant long-term post-surgery psychological and psychiatric pathology[19], including persistence of suicide attempts, and suicide mortality [22]).

The associated references are then (the links are above if you want them):

[19]“In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); [...] and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.”“Future research is needed to ascertain the potential harm of hormonal therapies(176).” “Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).” "We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.”

[20] (1) and (2) “The critical outcomes for decision making are the impact on gender dysphoria, mental health and quality of life. The quality of evidence for these outcomes was assessed as very low certainty using modified GRADE.”

This is a new reference, replacing the old evidence reference there earlier.

These two are from earlier, just copied here for completeness.

[21]"We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition."

[22]"In a nationwide long-term follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted as elevated after juridical and medical SR."

(This paragraph has the wording from before except for reassigning what 19 and 20 mean (19 is the old 20, 20 is the new ref), the first sentence going away, the removal of the "robust" clause at the end of the last sentence, and the second sentence adding a new reference. Aside from the removed references to the old 19, and the addition of the new 20 sentence, this is what I put in earlier. Removing the old 19 was according to @Kaldari:'s suggestion. The new ref 20 is a high quality evidence review which also found concerns with evidence quality.) As far as I can tell, this paragraph is in line with Wikipedia guidelines. And I do not see how the long citation to [19] violated COPYQUOTE. So, again, I am trying to reinstate the removed information about

(several have found significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality [22])

and the reference quotation supporting it. "significant risks have been found" was my paraphrasing of "significant long-term post-surgery psychological and psychiatric pathology[20], including persistence of suicide attempts, and suicide mortality". I was not offering to put my paraphrasing into the text. The insertion above, which was taken out, is in fact very close to what the literature actually says. These serious dangers are no longer listed on the page. Needing more studies is not the same as saying bad outcomes have happened. The latter is true. Neglecting it is imposing a POV. Thanks. Jdbrook talk 21:18, 24 April 2021 (UTC)

But what is the quality of the evidence of the several postoperative studies that report significant long-term psychological and psychiatric pathology, or which find a risk of persistent suicide attempts? I don't see anything in the passages you quoted concerning the quality of this evidence, and gaps or poor quality of evidence seems to be the main point of these studies, so this is puzzling to me. Newimpartial (talk) 21:34, 24 April 2021 (UTC)

If a treatment causes "significant long-term psychological and psychiatric pathology", the review authors have called the result, explicitly, significant. (It isn't for me to prove these studies are reliable to you, it's not about your judgement or my judgement of the studies, that is what the reviewers have done. I happen to know that one is long term, doesn't suffer loss to follow up, has clean assessment measures, and a comparison sample, an issues the review being quoted worries about for studies more generally. Other papers have also noted this paper is one of the more robust ones. We are not the ones writing the review here. The experts have already done so. If you are trying to delve into why the reviewers think this result is significant before accepting their evaluation, this may risk veering into OR.) Again, two authoritative review authors quote these poor outcomes. More studies are needed, as has been quoted. Some significant very bad outcomes (including suicide), a fact which is currently omitted. Thanks. Jdbrook talk 02:33, 25 April 2021 (UTC)

So when a secondary study states that the quality of evidence is poor, and that some of the primary studies report negative outcomes, but the secondary study does not state that the studies reporting negative outcomes are of higher quality than the others, then how do you reach that conclusion? Should we not rather conclude that the evidence of negative outcomes, like the evidence of positive outcomes, is poor, according to the secondary studies? Newimpartial (talk) 03:03, 25 April 2021 (UTC)

I don't see in their article any comment suggesting that in this sentence

"Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)."

is something that should not be considered reliable. They have used their expertise to decide to report it. Are you suggesting that this is not to be believed, although they chose to say it? (Again, if you want to go into trying to read their minds, one of the major studies seeing this result is long term, has controls, measures if people die or not, a clear assessment measure, so it does not have seem to have issues they mention elsewhere. Perhaps, but I am not the authors, that is why they considered it valuable enough to bring up. But I cannot read their minds about it.) I am not following why you wish to conclude that something significant they report, dangers, should not be quoted, in spite of the fact that they used their expertise to decide what to include and what not to include. Thanks. Jdbrook talk 23:52, 25 April 2021 (UTC)

Perhaps my point is too elementary for you to recognize, but it seems to me that if a secondary study reports that the evidence on a topic is poor, and that some of the evidence on that topic points to certain risks, that the first statement also applies to the evidence for the second unless the authors specifically exclude the studies backing up the second point. You seem inclined to conduct OR to validate that the studies backing the second point are stronger than those referred to in the first point, but we aren't supposed to do that, are we? Am I missing something? Newimpartial (talk) 00:53, 26 April 2021 (UTC)

It appears to me that it is OR or POV for a Wikipedia editor to decide that something a reliable WP reference says is not to be trusted and should not be quoted. If experts have decided to put a statement in a review and a WP editor has decided it is not reliable, the WP editor is second-guessing them. They explicitly say:

"Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)."

You are saying that the statement they made is not to be trusted. Another possibility is that the quality of evidence restricts what they can reliably say. Your theory that they include results that they don't trust and that the reader is supposed to guess which ones are trustworthy seems much less likely to me.

Thanks. Jdbrook talk 02:02, 26 April 2021 (UTC)

Not at all. I am saying that the authors of the secondary study make the second statement in the context the first, and we should interpret it in the same manner rather than ripping the second statement out of context (as e.g. you did when you said that Significant risks have been found, above). Newimpartial (talk) 02:13, 26 April 2021 (UTC)

The context for this statement is that the paragraph where it appears starts with

Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult. However,...

And the statement we are discussing is part of the "however", i.e., things they can reliably report. Thanks. Jdbrook talk 02:24, 26 April 2021 (UTC)

Could you let me know what study you are citing? You haven't quoted that text before, so I have no idea. Newimpartial (talk) 02:33, 26 April 2021 (UTC)

Never mind; I think you are referring to this one. If so, I'm afraid I don't find that the text supports your reading. The paragraph beginning, Owing to the lack of controlled studies does not in any way suggest that the results it points to are somehow based on anything other than the lower-quality evidence they discuss elsewhere, for precisely the reasons they note in that sentence. So yes, having read the whole paper again, I still think you are ripping the authors' observations about psychological and psychiatric pathology out of context - not only do they preface the statement with the caveats we have been discussing, but their conclusion is that We need more studies with appropriate controls, which is rather different from your conclusion that Needing more studies is not the same as saying bad outcomes have happened and that NPOV calls on the WP article to state the latter. Our article should never go out in front of the evidence provided by the RS, and the authors of the study simply do not conclude that bad outcomes have happened - rather, they repeat over and over that more studies are needed. Newimpartial (talk) 02:55, 26 April 2021 (UTC)

Hembree et al, 2017, say more studies are needed. They decided to include some results in their review nonetheless. You asked for further evidence, beyond the fact that they have included this result, that one could quote this result, because they say more studies are needed. Again, this phrase appears in a paragraph which begins with:

Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult. However,

followed by the rest of the paragraph. The rest of the paragraph is a list of findings, observations, reports that they have decided are worth mentioning, because they have chosen to mention them. This supports the interpretation that there are difficulties but that they find certain results (i.e., the contents rest of the paragraph) worth mentioning. You seem to be saying that these results should not be taken as reliable, even though they have signaled they are important both by how they quote it and the fact that they include them in the first place.

You specifically asked why they had not indicated they are quoting something reliable (besides the fact that they have put it in their review). They did indicate it is worth reporting in this second way as well. I've answered your question as to why this should be included even though more studies are needed. Thanks. Jdbrook talk 12:25, 27 April 2021 (UTC)

But surely it would be inappropriate to insert what you have called the bad outcomes without acknowledging, as the study's authors do, that these are based on evidence they call lower-quality? Newimpartial (talk) 15:36, 27 April 2021 (UTC)

You asked me to show you where the article noted that these results were to be believed, given that there are issues with evidence in this field (which includes your assessment that they would include results that are not to be believed). I have done so.

I can repeat again: the authors specifically say, "Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult. However..." and then a list of results. In what way does this context imply that the following sentences in this paragraph, including " Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)." are not reliable?

Again, in the "however" they list some positive outcomes (some positive outcomes are already given in the Wikipedia article). The need for more research (already noted in the Wikipedia article). Some negative outcomes (now absent from the Wikipedia article because this information has been taken out).

So, although this review states "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)", all that remains in the Wikipedia article are statements about needing more studies and positive outcomes. As it stands, omitting these negative outcomes, the current Wikipedia article appears to be biased, with POV. Thanks. Jdbrook talk 22:31, 27 April 2021 (UTC)

The second half of the paragraph in question reads:

Another analysis demonstrated that, despite the young average age at death following surgery and the relatively larger number of individuals with somatic morbidity, the study does not allow for determination of causal relationships between, for example, specific types of hormonal or surgical treatment received and somatic morbidity and mortality (263). Reversal surgery in regretful male-to-female transsexuals after sexual reassignment surgery represents a complex, multistage procedure with satisfactory outcomes. Further insight into the characteristics of persons who regret their decision postoperatively would facilitate better future selection of applicants eligible for sexual reassignment surgery. We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.

How it is that this paragraph could be appropriately summarized as what you have called the bad outcomes, I have no idea. The balance of the available literature - including that cited in the article in question, and other sources - consists of statements about needing more studies and positive outcomes. If there are reliable studies reaching conclusions about negative outcomes, I have yet to see them. This study certainly is not it, and only cherrypicking would allow it to be used to say so. Newimpartial (talk) 22:44, 27 April 2021 (UTC)

You seem to be engaging in special pleading. The paragraph you quote above does not contradict "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)." [14] at all. The reliable studies are right there, and describing this as a "study" is misleading, as it is actually a top-shelf WP:MEDRS review article. Jdbrook, you are welcome to add a sentence that, in whole or in part, summarizes this aspect of the review. Crossroads ^-talk- 01:04, 28 April 2021 (UTC)

I am disappointed that you would accept that kind of cherrypicking. I am not sympathetic to that approach at all. The proposed text does not in any way summarize the content of those three pages - it reports a minor point while decontextualizing it and thus changing its meaning. Newimpartial (talk) 01:24, 28 April 2021 (UTC)

From where I stand this looks like reverse cherrypicking. 'We can relay what the review article says, except for anything negative.' Crossroads ^-talk- 22:40, 28 April 2021 (UTC)

I agree with newimpartial, the suggested additions are not well supported by the texts without some needed explanations or caveats. For example, the ref notes that the studies don't show causality, that they lack control, and there isn't mention of the first main takeaway from that article that the large study of studies found satisfactory results with functionality and cosmetic appearance after srs. Rab V (talk) 23:40, 28 April 2021 (UTC)

New source

This seems like a potentially useful and reliable secondary source, I believe. Newimpartial (talk) 15:33, 5 May 2021 (UTC)

Clarifying for passersby that it's from 2016, so not new per se, but yes. Crossroads ^-talk- 06:26, 6 May 2021 (UTC)

Publication date is 2021, is it not? Newimpartial (talk) 11:20, 6 May 2021 (UTC)

My bad, it is. I apparently assumed you posted the same link here as you did at the other article around the same time; I thought I checked they were the same but I must not have. Crossroads ^-talk- 04:47, 7 May 2021 (UTC)

Merge of gender euphoria to gender dysphoria

Hi, I just transferred the content from gender euphoria, an article discussed at AfD with the result Merge with gender dysphoria. See discussion at Wikipedia:Articles_for_deletion/Gender_euphoria Please respect the consensus there. Feel free to move the content around if you think it works better in a different section ‎⠀Trimton⠀‎‎ 14:39, 15 May 2021 (UTC)

Note that my move was the second attempt at move. The first attempt had been reverted by a user who disagrees with the consensus. Note that WP:CON says in most cases, an editor who knows a proposed change will modify a matter resolved by past discussion should propose that change by discussion. Disagreeing with a deletion closing is such a case and if you think you can overturn the consensus, then the discussion should be taken to WP:DRV. Those chances are low in my view. As I argued at AfD, the sources cited meet WP:MEDRS. Note also that MEDRS might not apply to a society section anyhow, even less when the medicalisation of gender dysphoria is disputed by WP:RS in that same section. ‎⠀Trimton⠀‎‎ 00:38, 16 May 2021 (UTC)

Local consensus at an AfD does not override project-wide consensus of WP:MEDRS. Furthermore, people voting "merge" in an AfD are, unless they specify content, assumed to be voting for only encyclopedic, non-duplicitous, and well sourced material to be merged - not a cut and paste merge without any discretion used. -bɜ:ʳkənhɪmez (User/say hi!) 23:08, 16 May 2021 (UTC)

Exactly. In fact, I'd argue that both the relisting of the AfD and its closure as merge were bad closures. There were, in total, 10 votes to delete or redirect it, and only 7 to merge (and one of those was "merge/redirect"). It was 9 to 5 to delete at the time of the relist. I'm not going to waste time challenging the official close, but a merge closure is not immunity for any and all content in the article at its destination. WP:MERGETEXT states, Copy all or some of the content from the source page(s) and paste the content in an appropriate location at the destination page. Don't just redirect the source page without copying any content if any good content from the source page exists. (Emphasis added.) Crossroads ^-talk- 03:00, 17 May 2021 (UTC)

WP:MEDRS must be respected. In the case of an Afd closure of "Merge", that means, basically, "merge any policy-compliant text into the target article, without duplicating existing material". If the source article contains no such text, imho it's fully compliant of the merge closure to move nothing to the target; in that case, I'd add a dummy edit to the target, stating in the edit summary something to the effect that the merge result [add discussion link] is being complied with, and the result is that there is nothing policy-compliant in the source that can be moved. Mathglot (talk) 08:07, 11 June 2021 (UTC)

No Comorbidity Section

I don’t understand why there is no Comorbidity section I mean autism spectrum and Schizophrenia have comorbidity sections. Also Conditions comorbid to autism spectrum disorders mentions that Gender Dysphoria occurs more in autistic people.CycoMa (talk) 15:59, 25 May 2021 (UTC)

I haven’t read the whole study but this study may be useful.CycoMa (talk) 16:13, 25 May 2021 (UTC)

Considering your edit history and a brief look at your twitter activity, I doubt this edit proposal is in good faith. VariousDeliciousCheeses (talk) 17:26, 9 June 2021 (UTC)

VariousDeliciousCheeses That’s kind of irrelevant to this discussion. Also just because someone has certain views on a topic doesn’t mean they are breaking the rules.

I try my best to keep my personal beliefs off Wikipedia and stick to what reliable sources say on a topic. Which is what I have been doing here this whole time.

If a majority of scientists agree the earth is round, Wikipedia says it is round even if such a view is controversial among flat earthers.

Also I presented a reliable source in this talk section? So I’m spreading any form of propaganda.CycoMa (talk) 17:48, 9 June 2021 (UTC)

I mean the source I presented mentions that many individuals with Gender Dysphoria has have autism.

Source I presented said this.

“These studies have identified that between 4.8% and 26% of individuals who present at GD clinics have an autism diagnosis”

So yeah.CycoMa (talk) 17:58, 9 June 2021 (UTC)

Sorry grammar what I met to say was.

So it’s not like I’m presenting any form of propaganda.CycoMa (talk) 17:59, 9 June 2021 (UTC)

VariousDeliciousCheeses, if you have an issue with another editors conduct, it's best to bring that up on their user talk page. This space should be focused on improvements to this article. CycoMa, I do think it makes sense to have a Comorbidity section, but I wouldn't advocate for centering it on one primary study. There are hopefully some MEDRS secondary sources that can cover the various comorbidities. Firefangledfeathers (talk) 18:29, 9 June 2021 (UTC)

Firefangledfeathers I know there are more sources on this. Like the article on Conditions comorbid to autism spectrum disorders has like 5 sources stating a lot of autistic people have Gender Dysphoria.

I’m just too lazy at the moment to do further research.CycoMa (talk) 18:33, 9 June 2021 (UTC)

To clarify, I don't mean more sourcing that people experiencing GD are more likely to have ASD or vice versa. If we want a section on Comorbidity, we should mention all comorbidities mentioned in reliable, secondary sources. I am no expert on what's out there in the literature. Something like this study—just an example, I haven't read it and can't vouch for it being reliable. Firefangledfeathers (talk) 18:40, 9 June 2021 (UTC)

Firefangledfeathers I kinda understand that I was just presenting an example. Since a lot of sources mention comorbidity of ASD and GD.CycoMa (talk) 18:43, 9 June 2021 (UTC)

With [this source] do?CycoMa (talk) 19:15, 9 June 2021 (UTC)

[Here’s] another source. I may take the sources to Reliable source noticeboard to discuss this with them.CycoMa (talk) 19:24, 9 June 2021 (UTC)

@CycoMa: Both the Meybodi source and the Gordiano source are primary sources, so no, they won't do. Please remember that WP:MEDRS applies to the topic. Equivamp - talk 23:23, 9 June 2021 (UTC)

@CycoMa: Here is a secondary, already cited on the page, this [link] goes to the comorbidities section. (Comorbidities are also mentioned elsewhere in the article.) It doesn't include all the comorbidities mentioned in several primaries, e.g. trauma, OCD, though, so it is not an exhaustive list. But it does mention ASD and eating disorders, similar to some of the suggested primaries. Thanks. Jdbrook talk 02:38, 11 June 2021 (UTC)

This is definitely usable. Crossroads ^-talk- 03:02, 11 June 2021 (UTC)

@CycoMa: bear in mind also, that "comorbidity" is not commutative when prevalence is widely disparate among two conditions. For example, it's perfectly possible for sources to confirm that GD is a top comorbid condition for ASD, at the same time that they confirm that ASD is not a top comorbid condition for GD. So, please watch for that, and don't make assumptions based on the sources (especially primary, but also secondary) that you find at the ASD article. I'm not saying it is, or it isn't; I'm saying that they are two different propositions, and each needs its own sourcing; you cannot simply "borrow" the comorbidity sources from ASD and just plunk them down here, and expect them to work. This is not a MEDRS issue; it's a statistical (arithmetic) issue. Mathglot (talk) 08:19, 11 June 2021 (UTC)

Mathglot for clarification I mainly brought up ASD and GD because personally that’s the most well known example.

I know there are more examples, like I read sources say individuals with GD may also suffer from Anxiety or Depression.

Also the reason I brought this up is because a lot of other medical articles have sections on comorbidity.CycoMa (talk) 14:22, 11 June 2021 (UTC)

Also I believe [this] may be useful.CycoMa (talk) 14:26, 11 June 2021 (UTC)

Question about appropriate psychotherapy reference

Advice please

Hi, nothing on the page notes that gender dysphoria can sometimes (no one knows how often) be secondary to another condition (trauma, autism spectrum disorders, OCD, separation anxiety, etc.). There is no review of all the different studies which have found this, rather, there is one on OCD, several case studies, etc. It seems the current information is incomplete, as it only lists psychotherapy as a way to adjust to gender dysphoria, while, when gender dysphoria is secondary, psychotherapy can resolve it. I was wondering what reference might be appropriate or how to change the (currently misleading) wording, as the current wording only refers to the former? There are papers that review psychologists (e.g., https://pubmed.ncbi.nlm.nih.gov/12832250/, an older article), or mention the literature (e.g., https://link.springer.com/article/10.1007/s10508-020-01844-2 , in the discussion), or mention examples or the many case studies. Here is another example, https://onlinelibrary.wiley.com/doi/10.1111/1468-5922.12641 (search for Az Hakeem to see one therapeutic approach). Each of the case studies is a primary source. However, the existence of such people, who were helped by psychotherapy, is missing entirely.

As it stands, the article omits mention of sometimes effective supporting therapeutic exploration (the least invasive, and in the case studies, at least sometimes highly effective).

It is not known how often any of these approaches (psychotherapy, hormones, surgery) work to help and how often they harm, outcomes are not followed. The incomplete description of treatment options can be extremely misleading as it stands right now. Please advise? Thank you. Jdbrook (talk) 03:44, 23 February 2021 (UTC)

Hi, can you please confirm that you have read WP:MEDRS? It's really important for this topic. Regarding the 3 sources mentioned here, the 1st is a primary source and is a survey of psychiatrists. It is rather old, from 2003; I don't think this is a good option. The second does not seem to review any studies about GD being secondary to/resulting from other conditions. It's a criticism of a different study by Turban et al., which we also would want to avoid as a primary source. The third comes from a journal of Jungian psychoanalysis, which is not mainstream psychology or psychiatry.

To quote MEDRS: Ideal sources for biomedical information include: review articles (especially systematic reviews) published in reputable medical journals; academic and professional books written by experts in the relevant fields and from respected publishers; and guidelines or position statements from national or international expert bodies. Do you have anything like that? Crossroads ^-talk- 05:06, 23 February 2021 (UTC)

Hi, hello again. Reference 2, in the Discussion, reviews the literature. The rest of the article is indeed a rebuttal. Perhaps it is appropriate to put the parts from the discussion, or something else?

"Further, GD can present as a transient symptom that resolves spontaneously or in the context of developmentally informed psychotherapeutic treatment. Some common examples of transient gender-dysphoric states include adolescents girls, often on the autism spectrum, experiencing distress around the physical and social changes of puberty or gender-non-conforming young women struggling with shame about being seen as “butch.” These individuals, searching for ways to understand and remedy their distress, can incorrectly attribute their discomfort to being transgender. Several case reports (Churcher Clarke & Spiliadis, 2019; Lemma, 2018; Spiliadis, 2019) indicate that the distress of young people with GD can lessen or resolve with appropriate psychotherapeutic interventions that address the central issues."

Here is a 2018 review article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841333/

"More empirical research is needed regarding virtually all aspects of GD in adolescence to create treatment approaches that optimize these young people’s future psychosocial health and well-being. It seems unlikely that all the psychopathology observed in the referred samples is secondary to gender identity issues and would resolve with hormonal and later surgical treatments. There is still no clear consensus regarding hormonal treatment for adolescents because long-term data are unavailable;36 actually, only one long-term follow up has been carried out, with a highly selected intervention group and an at baseline non-comparable comparison group."

Perhaps that is better to use? There are many case reports (including an entire group of people, reported in the Jungian article, which, indeed, is not a review), but a summary paper is hard to find. I will keep looking if these aren't good. It seems misleading to not have this option mentioned, that other underlying things can cause gender dysphoria, and thus need to be addressed, and might resolve it, if someone is looking at ways to treat it. It is very surprising on the surface that trauma, or OCD or being on the spectrum might cause it, and yet, it does, at times. But they are all primary articles. However, the medical treatments are also not based on high or moderate quality evidence, either, so it is quite an evolving issue. Thanks!

Jdbrook (talk) 19:16, 25 February 2021 (UTC)

This [15] 2018 review article that you mentioned looks good; it would be best to use that. Crossroads ^-talk- 07:16, 27 February 2021 (UTC)

Thank you, shall do. Jdbrook (talk) 16:17, 27 February 2021 (UTC)

So...that 2018 reference, once I read it more carefully, is inadequate for indicating or summarizing the use of psychotherapy for underlying issues. I'm sorry for not catching that sooner. There are plenty of studies with examples, above, and e.g., Withers https://onlinelibrary.wiley.com/doi/full/10.1111/1468-5922.12641 ,

Hakeem’s inspired idea of mixing the two groups together produced remarkable results. About a quarter of his participants had medically transitioned but were still gender dysphoric, while about two thirds were awaiting medical treatment. The rest identified themselves as drag queens, transvestites, etc. Hakeem reports that after a while, the post‐surgical group of regretters became more hopeful (ibid., p. 150). He also mentioned, almost in passing in a public lecture (Hakeem 2018b), that only two of the 100 or so pre‐surgical patients he saw went on to medically transition. The other 98% gave up their desire for medical treatment.

and verbal reported outcomes.

Besides the case studies mentioned above (both immediately above, and the other two references) there are also Asperger's case studies, https://journals.sagepub.com/doi/full/10.1177/1039856213497814 and 2006 guidelines, here: https://doi.org/10.1300/J485v09n03_03 which advise (their Fig. 1) to not proceed with treatment for gender issues until OCD is accounted for. And then to reassess whether gender dysphoria is still present. This is a 2006 guideline, however a 2007 paper is also quoted on the page we are talking about. I'm not sure what is appropriate to mention, it seems worth pointing out that OCD, ASD, trauma, etc., can lead to gender dysphoria and that treating these can resolve the dysphoria, so people learn this is possible.

If you have time for thoughts?

Perhaps https://journals.sagepub.com/doi/abs/10.1177/1359104518825288 which is a joint case review? Or the 2006 guidelines which talk about OCD? Thanks! Jdbrook (talk) 23:35, 27 February 2021 (UTC)

In any case this 2018 review is an ideal source. Now, as far as the rest, I noted previously that the Jungian journal and case reports are not WP:MEDRS sources. Articles are to be based on which source(s) are strongest per MEDRS. If proper sources can't be found, then something can't go in. And stronger sources outweigh weaker ones. I recommend proposing text based on the kind of source MEDRS says is best. See the pyramids at WP:MEDASSESS (part of MEDRS), for example. Perhaps what the high quality sources state may be less definite than you prefer, but that's how it has to be. Keep in mind that weakly sourced material is likely to be challenged on a topic like this; if not by me, than by someone else. Crossroads ^-talk- 06:00, 28 February 2021 (UTC)

Hi, thank you. This reference is not about psychotherapy for underlying mental conditions which can cause gender dysphoria, and when treated, can cause it to resolve. It is certainly a very good source for other things. I made a mistake in thinking it dealt with treating psychological conditions which might in some cases cause gender dysphoria. It mentions the other conditions, but the papers I am discussing are about psychotherapy for underlying conditions which, when treated, sometimes resolve the gender dysphoria (not by discussing the gender dysphoria, but by treating the other things). For instance, GD might be caused by OCD, which is why this one says to first treat OCD before you consider any sort of gender dysphoria treatment, and that in fact you should not assess gender dysphoria first, as the OCD might confuse the diagnosis. From WP:MEDRS:

If conclusions are worth mentioning (such as large randomized clinical trials with surprising results), they should be described appropriately as from a single study:

"A large, NIH-funded study published in 2010 found that selenium and Vitamin E supplements, separately as well as together, did not decrease the risk of getting prostate cancer and that vitamin E may increase the risk; they were previously thought to prevent prostate cancer." (citing PMID 20924966)

Given time a review will be published, and the primary sources should preferably be replaced with the review. Using secondary sources then allows facts to be stated with greater reliability:

"Neither vitamin E nor selenium decreases the risk of prostate cancer and vitamin E may increase it." (citing PMID 29376219PMID 26957512)

In this case, perhaps this guideline would justify including the interesting study which is recent, and which should be removed in a year or two if not included in a review?

It is also a surprising (to some) result, and seems important to make known, for this reason. This would be the response to a criticism to remove it. It is a review of case studies, but I agree it is only a one paper review of case studies. It also does not have any papers which have claimed that it is false, as far as I know (but I'm sure people who wish to remove it will educate me if I am wrong about it!). There are several other case studies with similar results, so I am guessing a review will be forthcoming. Thanks for the help figuring this out! Jdbrook (talk) 08:20, 28 February 2021 (UTC)

While MEDRS does technically allow for lower quality sources at times, such is discouraged for good reasons. And this subject is quite a bit more controversial than prostate cancer, as I'm sure you know. I know from experience that such things will be challenged and that we should stick to rock-solid sources from the beginning. But, out of curiosity, what article text would you source to that study, based on what quote from it? Crossroads ^-talk- 05:38, 1 March 2021 (UTC)

@Crossroads:Hi, how about this for psychotherapy? It turns out one of the review articles that I thought was too old is actually being used in the article, so I have quoted from it (ref 48). Here is a suggestion.

Many adolescent-onset cases have GD in the context of severe mental disorders and general identity confusion, where appropriate treatment for psychiatric comorbidities “may be warranted before conclusions regarding gender identity can be drawn.”[16] It is known that some mental disorders are important to evaluate and treat before proceeding with hormones or surgery, as treatment of these mental disorders can sometimes make the wish for altering one's body disappear or significantly lessen.(Ref 48)

in the footnote for the latter, from the reference "[DOI: 10.1300/J485v09n03_03] [..]As per Figure 1, delusions about sex or gender, dissociative disorders, thought disorders,or obsessive or compulsive features should be evaluated and treated prior to proceeding with hormone therapy or surgery. Thought disorders, dissociative disorders, and obsessive-compulsive disorders can, rarely, cause a transient wish for sex reassignment which disappears or significantly lessens when the underlying mental health condition is treated. It is important to treat these disorders before proceeding with hormones or surgery to ensure that the desire for alteration of primary or secondary sex characteristics is not a temporary desire." What do you think? Too long? Thanks! Jdbrook (talk) 05:14, 13 March 2021 (UTC)

Looks good to me, but that second sentence should probably be tweaked to be clear that in those cases, the wish for reassignment is a temporary/transient one caused by the condition. I'd also swap the order of the sentences around since the latter is not only about adolescents and putting it after the other one may make it seem like it is. Crossroads ^-talk- 07:09, 13 March 2021 (UTC)

Thank you. It turns out once you reverse the order, the sentence about adolescents is more either about diagnosis or the value of psychological treatment, so I have split the two phrases and put them in different sections. I also added more references to WPATH and the Dutch Protocol for looking for other conditions, to help the reader. Thanks a lot. Jdbrook (talk) 01:55, 16 March 2021 (UTC)

Really, we are going to rely on this one reference to characterize adolescent gender dysphoria in two sentences? The study itself may be flawlessly MEDRS, but with many papers on the topic, it's odd to lean heavily on just the one. Especially this one: The study abstract itself says that their findings deviate from current mainstream view - "The findings do not fit the commonly accepted image of a gender dysphoric minor". We could do better to portray the bigger picture with more sources. There's some secondary literature out there too; policy documents and guidelines often use literature survey methodologies. CyreJ (talk) 08:31, 9 June 2021 (UTC)

References

Evidence base for treatments

Equivamp A comment of "Original Research" was inserted in the lead on the comment of the status of various treatments for GD. This comment should be removed since this section is subject to strict WP rules for exceptional care with medical information. A treatment must be assumed "not evidenced" unless otherwise sourced with WP:MEDRS compliant reliable sources. The edit is therefore not original research, it is clarification of the status. KoenigHall (talk) 09:52, 11 June 2021 (UTC)

WP:MEDRS does not say we should do our own original research about the basis for treatments, or make any assumptions not based on what the sources say. Previously you stated your edit was backed by Numerous reliable sources, but now when pressed to cite them you've declined to, and gone so far as to say that reliable sources are needed to justify not saying it. It's pretty clear that these sources don't exist and where the burden lies. Equivamp - talk 14:05, 11 June 2021 (UTC)

I headed over to the article to confirm, and to remove the original research if needed. Thankfully, it already has been. Mathglot (talk) 16:32, 11 June 2021 (UTC)

Equivamp I did not see I was "pressed for sources". There are plenty of very reliable sources (e.g Endocr Soc guidelines 2017, one of many) but my understanding is that the burden of proof is on whoever claims the treatments are validated and evidence based. This presumed "inversion of burden of proof" is part of my point here. As you know, WP rules demand that medically relevant information be carefully screened, in particulr pertaining to treatents. The fact that a number of editors object to qualifying the statement that treatments are not evidence based accentuates the need to actually include this clarification so that readers who are not well informed not be misled by the WP article to believe treatments are. Since I have been blocked for two weeks I will come back to this later. KoenigHall (talk) 12:27, 12 June 2021 (UTC)

Is this the source you mentioned? Can you care to point out where, in your view, it substantiates your viewpoint? From what I can see, the guidelines are appended with a GRADE ranking, which means that by definition it is based on evidence (of a quality ranked by the GRADE scale). Equivamp - talk 12:39, 12 June 2021 (UTC)

Toward some better language in the Treatment > Children sub-heading

The first line under the Treatment > Children sub-heading reads as follows:

The question of whether to counsel young children to be happy with their assigned sex, or to allow them to continue to exhibit behaviors that do not match their assigned sex—or to explore a gender transition—is controversial.

I realize that due to the sensitive nature of the topic, it's probably very difficult to come up with satisfactory language here; but I think the current version of the language needs some revision. The wording "be happy with" seems too informal and possibly loaded, and "allow them..." seems a bit too suggestive of severe control (as opposed to using a verb like "encourage"). "Behaviors that do not match their assigned sex" is also highly ambiguous: who or what dictates which behaviors "don't match" an assigned sex?

Further, I'm not sure if this implies only clinical treatment here, or if parents are implicitly included in this, too — though I'm assuming the latter, because what authority does a clinician have to "allow" children to exhibit behaviors or not? In light of this, I think it's worth being a bit more explicit about who the subject of the "counsel" is. (Though, again, I'm not exactly sure if parents should be included in this.)

So in light of these things, I think the sentence could use some major overhaul. Again, it's going to be hard to craft a sentence that navigates these complicated issues and still remains succinct, but my thought was something like this:

The question of how child gender dysphoria is to be approached by clinicians and parents is controversial—namely, whether to encourage children to remain comfortable with their assigned sex, or to encourage them to engage in behaviors that do not match their assigned sex, as variously conceived; or otherwise to explore a gender transition.

If it's solely clinicians that are in mind here, then obviously the first words could be modified to "The question of how child gender dysphoria is to be treated by clinicians..."

Another alternative would be to split the sentence into two — something like this:

There is widespread disagreement in the medical and academic community about how child gender dysphoria is to be handled by clinicians and parents. Various recommended approaches include encouraging children to remain comfortable with their assigned sex, encouraging them to engage in behaviors that do not match their assigned sex, as variously conceived, or to explore gender transition.

I think this is probably a better alternative than my first recommended sentence.

Ostensibly1 (talk) 19:12, 15 June 2021 (UTC)

I actually thought "allow" was less rigid, I read it to mean that the young person may or may not have guardrails put up, but is not being pushed/steered in various directions. It seems we read it in opposite ways. You might allow them to engage in certain behaviors without encouraging them ("watchful waiting" I believe is like this, but am not sure). Thanks. Jdbrook talk 04:35, 21 June 2021 (UTC)

surgical treatment results issue with WP:DUE

Currently, in the treatment section, there is the phrase "Gender-dysphoric patients who choose to undergo sex reassignment surgery report high levels of satisfaction." which quotes a 1999 article (Carroll) and a 2007 review (Gijs and Brawaeys). However, the 2007 review has qualifications regarding the results it reports, which are not on the page. In the section called "The Effectiveness of SRS in Adults: A Commentary," the authors say:

Methodologically, however, this conclusion should be carefully qualified.

In addition to the design problems of the studies, patient numbers are seriously skewed. A large number of patients who received surgery were lost at follow-up (see Table 1): For the FMs the attrition rate varies between 0% and 81%, with an average of 24% (based on Boldund & Kullgren, 1996; Eldh et al., 1997; Hepp et al., 2002; Lobato et al., 2006; Raufleish et al., 1998; Smith et al., 2005a, Tsoi et al., 1995). For the MFs, between 0% and 73% did not participate in the follow-up, with an average attrition rate of 39%”[...]”effects of SR were not always evaluated at the same point in the treatment process.

Different measurement instruments, some with unknown validity, have been used.

This seems to be an issue of WP:DUE. To make the sentence about surgery results from this source more accurately reflect the qualifications stated in the source, how about something like the following?

Gender-dysphoric patients who choose to undergo sex reassignment surgery have reported high levels of satisfaction in studies, however, the results from these studies should be qualified due to design problems, loss of many people to follow up (24% average FTM, 39% average MTF), and timing and measurements that were hard to compare.

Thanks. Jdbrook talk 03:32, 21 June 2021 (UTC)

I'm not sure what you mean by this is a DUE issue. The high satisfaction rates post surgery are discussed without these qualifications in reliable high quality secondary sources like WPATHs SOC. Rab V (talk) 07:18, 21 June 2021 (UTC)

I suggest we look to replace these two sources with newer reviews, and see what they say. If they all or mostly state similar qualifications, then that should be noted, but we'll see what they say. Crossroads ^-talk- 03:31, 22 June 2021 (UTC)

Thanks everyone. Here are some other papers discussing methodological issues with surgery results.

1. The Hembree et al (2017) Endocrine Society Guidelines claim " The satisfaction rate with surgical reassignment of sex is now very high (187)." (These guidelines are also cosponsored by WPATH.) Reference (187) is Murad et al 2010. In Murad et al 2010, the summary at the beginning says "Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life." In the article it says

The evidence in this review is of very low quality9, 10 due to the serious methodological limitations of included studies. Studies lacked bias protection measures such as randomization and control groups, and generally depended on self-report to ascertain the exposure (i.e. hormonal therapy was self-reported as opposed to being extracted from medical records). Our reliance on reported outcome measures may also indicate a higher risk of reporting bias within the studies. Statistical heterogeneity of the results was also significant.

2. There is also the comment in Hembree et al itself about surgical studies, although I believe @Rab V: has argued this is about surgery quality not satisfaction:

Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult.

3. There is also a 2009 review (only 2 years later than Gijs and Brewaeys):

The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.

4. WPATH quotes for outcomes: DeCuypere et al., 2005; Gijs & Brewaeys, 2007; Klein & Gorzalka, 2009, Pfäfflin & Junge, 1998. I am unable to get to the 2009 paper. However, the 2007 paper is in fact the one that is on the current Wikipedia page, with the methodological caveats that currently are not reported.

5. The Swedish evidence review quoted right after the sentence under discussion says:

The number of patients diagnosed with gender dysphoria increases rapidly as does gender affirmation surgery. The available literature includes only observational studies of mostly poor quality, comparative studies are few and data from long-term follow up are lacking.

These all seem to be noting methodological issues as well with surgery (and Murad et al it seems also has hormonal studies) outcomes.

Thanks. Jdbrook talk 05:34, 23 June 2021 (UTC)

From the SOC "Although Harry Benjamin already acknowledged a spectrum of gender nonconformity (Benjamin, 1966), the initial clinical approach largely focused on identifying who was an appropriate candidate for sex reassignment to facilitate a physical change from male to female or female to male as completely as possible (e.g., Green & Fleming, 1990; Hastings, 1974). This approach was extensively evaluated and proved to be highly effective. Satisfaction rates across studies ranged from 87% of MtF patients to 97% of FtM patients (Green & Fleming, 1990), and regrets were extremely rare (1–1.5% of MtF patients and <1% of FtM patients; Pfäfflin, 1993). Indeed, hormone therapy and surgery have been found to be medically necessary to alleviate gender dysphoria in many people (American Medical Association, 2008; Anton, 2009; World Professional Association for Transgender Health, 2008)." This is a review source from a major medical organization that cites primary studies and other review sources to say surgery is effective with rare regrets. Rab V (talk) 06:48, 23 June 2021 (UTC)

Yes, but the studies overall (which did find that, yes) appear to be of lower quality compared to how medical research should be done, at least as noted by a number of reviews. I suggest that Jdbrook propose a sentence and review article sources for it and we go from there. Crossroads ^-talk- 03:45, 24 June 2021 (UTC)

Still trying to figure out which later papers are good to suggest to cite (instead of Gijs and Brawaeys 2007). Thanks. Jdbrook talk 05:30, 25 June 2021 (UTC)

@Crossroads: It seemed difficult to find good recent reviews. Hembree et al 2017 quotes Murad et al 2010, so one possibility is to combine that and Sutcliffe et al 2009 which are both reviews to say:

Some studies report satisfactory outcomes for surgery, however there are issues with interpreting results because of limitations including bias and high loss to follow up. [17][18]

This is still somewhat problematic as some of the included Murad et al studies are hormonal therapy only, even though it is quoted in the Endocrine Society guidelines for surgical outcomes. (The other two papers cited by Hembree 2017 for surgery: "Additionally, the mental health of the individual seems to be improved by participating in a treatment program that defines a pathway of gender-affirming treatment that includes hormones and surgery (130, 144)" seem actually to be about hormones only (130) and sexual desire in trans persons (144).) There is also the more recent 2018 review right after the sentence we are discussing which notes poor evidence GRADES (page 8 in that reference). That review considers but then excludes some of the papers the earlier studies include. The underlying issue seems to be that many of the studies have methodological concerns. Thanks. Jdbrook talk 23:35, 27 June 2021 (UTC)

Thanks. I would keep the first part of the sentence more similar to what is already there. "However" is disfavored per WP:Editorializing (but I get why people suggest it). How about this? Gender-dysphoric patients who choose to undergo sex reassignment surgery report satisifaction with the outcome, though these studies are limited by bias and high loss to follow up. I think a quick clarification on what kind of bias could be good. Crossroads ^-talk- 04:32, 28 June 2021 (UTC)

Thank you (also, thank you for explaining about the "however," sorry about that and good to know).

It seems that "Gender dysphoric patients who choose" implies perhaps "*All* gender dysphoric patients who choose", which is a bit stronger than the original "report high levels of satisfaction" or "satisfaction rate with surgical reassignment of sex is now very high" (Hembree et al 2017) or " Some satisfactory outcomes were reported," (Sutcliffe et al 2009). So how about changing the first half to be slightly more qualified, and then adding "including" for limitations (reasons below)?

Those who choose to undergo sex reassignment surgery report high satisfaction rates with the outcome, though these studies have limitations including risk of bias (lack of randomization, lack of controlled studies, self-reported outcomes) and high loss to follow up.

"Including" might be appropriate, as the references also note concerns with retrospective design ("evidence has not collected data prospectively"), lack of validated assessment measures, and significant statistical heterogeneity of the results. Putting all of that in the sentence seemed like too much.

Perhaps the citations could then be:

(Hembree et al 2017): "The satisfaction rate with surgical reassignment of sex is now very high (187)." "Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult."

(Murad et al 2010): "The evidence in this review is of very low quality9, 10 due to the serious methodological limitations of included studies. Studies lacked bias protection measures such as randomization and control groups, and generally depended on self-report to ascertain the exposure (i.e. hormonal therapy was self-reported as opposed to being extracted from medical records). Our reliance on reported outcome measures may also indicate a higher risk of reporting bias within the studies. Statistical heterogeneity of the results was also significant."

(Sutcliffe et al 2009): "The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence."

There is still the issue that Murad is focussing on hormones and 5/28 of studies are of hormones only, while 23/28 are about hormones and surgery. And Hembree et al 2017 quote them for surgical satisfaction which isn't explicitly addressed (they find ~80% have improved: quality of life,gender dysphoria, psychological function, and sexual function). Maybe that is somehow the high satisfaction rates which they are being quoted for.

Would this work? Thanks. Jdbrook talk 03:44, 29 June 2021 (UTC)

Seems good to me. Crossroads ^-talk- 06:05, 29 June 2021 (UTC)

Using primary sources cited by secondary reviews to come to conclusions that are not in the secondary reviews is OR and that seems to be the basis for jdbrooks argument for making the proposed changes to the article. For this reason, and since secondary sources by major medical associations do not offer these caveats I would not be ok with this addition. Rab V (talk) 10:26, 29 June 2021 (UTC)

Thanks. The original secondary source already listed has the caveats which I suggested including, if you look at the top of this discussion. The issue was that this original secondary source was from 2007. So the more recent secondaries were what I was using, Murad (above, 2010), and 2. and 3. in the list above. (2) says "Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." I think I discussed with someone, maybe you, about how this applied to surgical outcomes, since it is said to be about approaches and techniques. Either way, at least 3 reviews, if you don't count (2), have these caveats about outcomes. These are all secondaries I believe. Thanks. Jdbrook talk 20:47, 29 June 2021 (UTC)

Jdbrook's comment that you are replying to seems to only analyze primary sources as a side point, not as part of the proposed text. Ultimately, that part doesn't really matter. If the medical reviews themselves make any mistakes that has to be corrected within the academic process; we can't do anything to compensate for that. Still, it remains that the reviews do emphasize the less than ideal quality of the studies that have been done. Crossroads ^-talk- 04:11, 30 June 2021 (UTC)

I'm unclear what change is cleared to make. The current references are not accurately represented on the page as it stands, as the results are quoted but not the limitations of those results. Is it ok to add the most recent proposed sentence, above? That is:

Those who choose to undergo sex reassignment surgery report high satisfaction rates with the outcome, though these studies have limitations including risk of bias (lack of randomization, lack of controlled studies, self-reported outcomes) and high loss to follow up.

Or does anyone recommend something different than this? Thanks. Jdbrook talk 16:06, 13 July 2021 (UTC)

Seems fine to me. Crossroads ^-talk- 04:45, 14 July 2021 (UTC)

Signs and symptoms

Shouldn't there be more than 2 sources for an entire paragraph? The information also seems biased and unscientific — Preceding unsigned comment added by RubyKDC (talk • contribs) 17:34, 26 June 2021 (UTC)

Those look like excellent sources. One is the DSM itself and the other is a secondary source review article published in a top-tier peer-reviewed publication. I wouldn't be opposed to including more sources if they're up to that standard, and I encourage you to bring them here if you find them. Firefangledfeathers (talk) 22:01, 26 June 2021 (UTC)

I think it is a good source (though we always want to use some caution when devoting too much text to relatively few sources), but I have WP:DUE concerns about pulling that specific paragraph, alone, almost verbatim out of the DSV and essentially ignoring the rest of the section. It doesn't reflect the diagnostic criteria particularly well, for instance, which makes it a poor choice for what is essentially the bulk of the section. The division between early- and late-onset gender dysphoria isn't a particularly major part of the DSV (it's mentioned once, on a single paragraph halfway through, in the Development and Course section.) I feel we should probably rewrite the section to focus more on the diagnostic criteria and especially on the various parts highlighted in the Diagnostic Features section, which are given more attention in the source. The current framing gives the impression that this division is the key thing that is used as a sign or symptom of gender dysphoria, which the sources absolutely do not support. --Aquillion (talk) 04:55, 28 June 2021 (UTC)

Agreeing with Aquillon that the focus in this section isn't where it should be based on actual diagnostic criteria from DSM. Rab V (talk) 10:29, 29 June 2021 (UTC)

I don't see any good reason to remove any of the points made, but material can certainly be added to account for points that are in the DSM, not covered, and that an encyclopedia would cover. Crossroads ^-talk- 04:12, 30 June 2021 (UTC)

That entire second paragraph has only two citations and those are right at the end. Considering the broad sweeping statements it's making I feel it's pretty disingenuous to just have those statements written when most of them really deserve a large "Citation Needed" marker next to them. Either cite your sources for these incredibly broad statements or just nuke most of that second paragraph in all honesty because as of right now it just reads like assumptions as opposed to anything resembling facts. Personally I'm with Aquillion in that this section really needs a major rewrite because in its current state it's mostly made up of uncited assumptions, especially the second paragraph. To add to this, I can't help but notice Crossroads seeming bias which very much shows up in most of their edits. Considering the context of the article, I feel that personal biases really shouldn't get in the way of the facts. The job of the article is to state the facts we know about gender dysphoria with proper citation, not slipping in bits of subtly biased bits and pieces that swing the article one way or another. 122.60.193.159 (talk) 01:17, 2 August 2021 (UTC)

Hmm, I may have caught a stalker, since this random IP with no other edits outside this article feels the need to opine on my editing. Read WP:NPA. We don't repeat citations over and over when a whole paragraph is sourced to the same two. See WP:REPCITE. The two sources there are top-quality WP:MEDRS, and the DSM-5 is the bible of psychiatry. Crossroads ^-talk- 04:26, 3 August 2021 (UTC)

Calling IP a stalker is maybe more uncivil than their note on editing bias. It is too bad though NPA does allow cover for biased editing to be directly discussed but that is often how it is used. Rab V (talk) 22:45, 7 August 2021 (UTC)

Other mental health disorders

Bodney with regards to your changes. There are like two reliable sources that mention individuals with GD have anxiety disorders.CycoMa (talk) 15:25, 7 August 2021 (UTC)

The fact they have anxiety disorders is highly unsurprising, every kind of person might have a range of anxiety disorders, but what causes the anxiety tells the reader more. ~ BOD ~ ^TALK 16:09, 7 August 2021 (UTC)

I don’t know the sources don’t really go in depth why. It could because of stigma, but I’m not sure about that.

To be honest Anxiety disorders are over diagnosed I was recently diagnosed with one and anxiety disorder is still on medical records even I don’t suffer it anymore.CycoMa (talk) 16:16, 7 August 2021 (UTC)

Actually I kind of need help with the Comorbidities section.CycoMa (talk) 16:56, 7 August 2021 (UTC)

Regarding this, if a source is a recent WP:MEDRS review, then it should be covered, but it is fine not to restore that until it is also noted whatever it says about the causes of what is observed. Crossroads ^-talk- 04:55, 8 August 2021 (UTC)

Tell that to the other editors whom reverted it.CycoMa (talk) 05:05, 8 August 2021 (UTC)

But without the context of the reasons researchers give for that finding, the statement is contentious and would have been disputed eventually. It should be included, but with proper context. Crossroads ^-talk- 05:15, 8 August 2021 (UTC)

I don't believe it is a scientific review article. Instead it is primary speculatory research since it comes to conclusions not in any of the articles it cites. Worth noting it is common for research papers to review relevant research but that doesn't make them a review paper. Rab V (talk) 00:35, 10 August 2021 (UTC)

To be clear, I think we are each speaking of two different papers. I'm talking about this one which just gave statistics, which I said should be better contextualized, while it was this one that offered a hypothesis. I agree on excluding that latter one. Crossroads ^-talk- 19:51, 10 August 2021 (UTC)

I agree with Rab's edit summary that this extraordinary claim would need stronger sourcing and different wording to be included. -sche (talk) 03:16, 10 August 2021 (UTC)

Anxiety disorder and anxiety

I believe I made a mistake when putting this in. Among youth, around 20% to 30% of individuals heading to gender clinics meet the DSM criteria for a anxiety disorder,[69] though anxiety seemed to increase due to internalized transphobia.

As someone who has been medical diagnosed with anxiety. I’m not sure having anxiety disorder and having anxiety are the same thing. Like that source said though anxiety seemed to increase due to internalized transphobia. The source for that statement said they had anxiety not an anxiety disorder.CycoMa (talk) 03:20, 19 September 2021 (UTC)

@CycoMa: But does the article text say something the source doesn't? If they have the disorder, the source may still say that anxiety increased with internalized transphobia. Crossroads ^-talk- 03:27, 19 September 2021 (UTC)

@Crossroads: that’s kinda what I need help with. I feel like I need help looking through those sources because I don’t remember the second source for that sentence mentioning anxiety disorder.CycoMa (talk) 03:30, 19 September 2021 (UTC)

Okay the source that says anxiety is high due to internalized transphobia comes from [this source]. Like I said I’m not a mental health professional but having at times anxiety doesn’t mean you have an anxiety disorder.

And I’m not sure if I’m misreading it or not but, it appears the source isn’t having anxiety means you have an anxiety disorder.CycoMa (talk) 03:40, 19 September 2021 (UTC)

GD and Transgender

Hey I saw this sentence added into the symptoms section. Transgender people are also at heightened risk for eating disorders and substance abuse.

I honestly think this sentence is unrelated to the topic of the article. I mean yes I know trans people experience Gender Dysphoria. But, Gender Dysphoria and transgender aren’t synonymous.CycoMa (talk) 18:21, 30 September 2021 (UTC)

Biological treatment biased consideration of methodological problems

The section on biological treatments only mentions methodological problems in studies supporting transition, whereas the Cochrane study that found no evidence in favor of hormonal treatment for trans women’s extreme selection criteria “We aimed to include randomised controlled trials (RCTs), quasi‐RCTs, and cohort studies that enrolled transgender women, age 16 years and over, in transition from male to female. Eligible studies investigated antiandrogen and estradiol hormone therapies alone or in combination, in comparison to another form of the active intervention, or placebo control. […] Our database searches identified 1057 references, and after removing duplicates we screened 787 of these. We checked 13 studies for eligibility at the full text screening stage. We excluded 12 studies and identified one as an ongoing study. We did not identify any completed studies that met our inclusion criteria.” goes entirely unmentioned. They didn’t find insufficient evidence because they didn’t find any studies at all that they were willing to consider as evidence! I’m not going to be able to have a neutral enough point of view to edit the section but I wanted to get another opinion after I put a template on the section because I might just have lower standards for the type of evidence I’m willing to consider than medical scientists have. Feralcateater000 (talk) 12:28, 16 October 2021 (UTC)

We can't second-guess the conclusions of WP:MEDRS, but I see you did add this review. We should probably move that down to that subsection, and that would help ensure it is balanced. Crossroads ^-talk- 23:40, 16 October 2021 (UTC)

Alright that would probably make the section more balanced. Thanks Feralcateater000 (talk) 13:21, 18 October 2021 (UTC)

Okay, I did it now. No problem. Crossroads ^-talk- 04:50, 19 October 2021 (UTC)

References