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"Gender-affirming care" for children necessarily includes puberty blockers

@XeCyranium: I would hope this was clear from other sources, but when a medical organization says that they oppose any laws and regulations that discriminate against transgender and gender-diverse individuals specifying explicitly that that includes children and adolescents, or that it strongly opposes any legislation or policy action that places restrictions on transgender health care and that criminalizes gender-affirming care, again specifying explicitly that it includes children, that is in fact necessarily support for puberty blockers even if they don't say so explicitly.

Now, I wouldn't be opposed to more explanatory text being devoted to each of these organizations explaining exactly what their positions are. I agree that it's relevant that many of these organizations are expressing a political opposition to restrictions on trans healthcare (and not, for instance, publishing medical recommendations on when puberty blockers are or aren't indicated). But don't just remove them! You're doing the equivalent of removing proofs about rectangles from the article on squares. Loki (talk) 01:31, 24 March 2024 (UTC)

I'm sorry but I disagree with the part where it needn't be explicit. It'd be like saying "the XYZ association supports the use of chelation therapy to treat mercury poisoning" but with a statement that only says "XYZ objects to legislation which would interfere with the treatment of mercury poisoning". But if you'd like to include it with a [better source needed] I'd understand. I mostly removed since I'd been surprised by the mention of a nursing association and thought it odd they would endorse a specific drug and then saw that their statement contained no such endorsement. XeCyranium (talk) 01:40, 24 March 2024 (UTC)
I did find an explicit source for the American College of Physicians here: [1] XeCyranium (talk) 01:56, 24 March 2024 (UTC)
And here's a source for the American Academy of Family Physicians: [2]. XeCyranium (talk) 02:20, 24 March 2024 (UTC)
This document from the American College of Obstetricians and Gynaecologists says that for the treatment of adolescents reference should be made to WPATH and Endocrine Society provisions so essentially supports it: [3]. XeCyranium (talk) 02:28, 24 March 2024 (UTC)
And I'm giving up on the American Osteopathic Association, they have the worst website layout imaginable on mobile, at least for me. If anybody is able to access it from another device it can be found at osteopathic.org. XeCyranium (talk) 02:35, 24 March 2024 (UTC)
Well, no, it's like an organization opposing laws against proper treatment of cancer and you removing that from the article on chemotherapy because they don't explicitly mention the word "chemotherapy". Puberty blockers are widely regarded to be the standard of care, so even if an organization doesn't mention them by name, if they talk about the standard of care in this area it does include puberty blockers.
I do agree that this is again a weird artifact of this being simultaneously a WP:MEDRS page and a page about a political controversy, but despite these most directly being statements about the political controversy they are also WP:MEDRS-quality sources about the treatment. Loki (talk) 02:04, 24 March 2024 (UTC)
I did find sources for three of the five organizations. To clarify what I mean with it needing to be near-explicit: I'm sure every medical body listed in this article would probably provide a statement to the effect of "we oppose any legislation that would seek to restrict treatment for transgender youth", but some of those same organizations don't endorse puberty blockers. Ergo I think an explicit endorsement is best. XeCyranium (talk) 21:51, 24 March 2024 (UTC)
LokiTheLiar please don't reinsert content with WP:VERIFIABILITY concerns unless you're going to use sources that actually support the statement you're including. If you're at a loss for sources I've posted some here in this very section. Please adhere to policy, if there are sources which actually support the content in question, which there are, use those. XeCyranium (talk) 21:28, 29 March 2024 (UTC)
The sources that were already there supported the statement I re-added. You looked at a bunch of sources that verified the claims, said they "failed verification" when they didn't, and then removed the claims for failing verification.
Feel free to add new sources but I dispute your removal in the first place or the idea the existing sources were in any way subpar. Loki (talk) 21:31, 29 March 2024 (UTC)
I would also like to get some extra eyes on this to avoid an edit war, so pinging past participants in similar discussions Snokalok, Your Friendly Neighborhood Sociologist, Barnards.tar.gz, Colin, TenorTwelve, WhatamIdoing and Sideswipe9th. Loki (talk) 23:03, 29 March 2024 (UTC)
I checked the page, it no longer exists. Could we get an archive or something? Snokalok (talk) 04:00, 30 March 2024 (UTC)
The disputed diff is this one and a few others like it going back and forth.
The TL;DR explanation of why there's a dispute is that I think sources saying an organization supports gender-affirming care for trans kids is sufficient to say that organization supports the use of puberty blockers (because puberty blockers are standard of care). XeCyranium thinks that a source must specifically say the organization supports puberty blockers. Loki (talk) 00:52, 31 March 2024 (UTC)
Loki, I'm sure you've got the facts right in practice, but I'd like you to think for a moment about the precedent here. If an organization says "We oppose laws against treating trans kids", there's a big difference between "supporting mainstream medical care, such as family counseling and puberty blockers in 10 year olds" and "supporting conversion therapy" (or "going straight to gender-affirming hormone treatment in 10 year olds" at the other end of the spectrum). We really do need sources that provide specificity. Fortunately, it looks like those sources are available. It'll just require some work to dig them up.
@XeCyranium, I don't think that AOA has an official organizational statement about puberty blockers on their website. They provide general information (e.g., https://findado.osteopathic.org/raising-a-transgender-child ) but no official statement. Such a statement might not exist, or it might be published in a medical journal instead of on their website. WhatamIdoing (talk) 02:02, 31 March 2024 (UTC)
Thank you for looking into the osteopathic association. XeCyranium (talk) 02:58, 31 March 2024 (UTC)
I appreciate you inviting more editors but I feel I should reiterate what I said in my edit summary, WP:VERIFY isn't subject to editor consensus on a talk page, whether the source says something or not isn't up for debate. I don't object to three of the orgs assuming the sources I've found are useable. But the source you're insisting on simply doesn't say what you're attaching it to. XeCyranium (talk) 03:19, 31 March 2024 (UTC)
The policy itself isn't but how to interpret it and, crucially here, whether the sources actually support the claim or not absolutely is. I've already explained why I believe the sources in question do in fact source those claims. Loki (talk) 03:21, 31 March 2024 (UTC)
I think it is reasonable for editors to discuss and agree on whether X => Y and can be assumed. I'm not sure Loki has done his case any favours by arguing for different reasons why X => Y. There are various statements mentioned above that are proposed as implicitly meaning support for puberty blockers but I don't think most of them would find consensus here. Some examples:
  1. oppose any laws and regulations that discriminate against transgender and gender-diverse individuals, including children and adolescents
  2. strongly opposes any legislation or policy action that places restrictions on transgender health care and that criminalizes gender-affirming care, again specifying explicitly that it includes children
  3. opposition to restrictions on trans healthcare
  4. opposing laws against proper treatment
  5. Puberty blockers are widely regarded to be the standard of care, so even if an organization doesn't mention them by name, if they talk about the standard of care in this area...
  6. an organization supports gender-affirming care for trans kids
  7. oppose laws against treating trans kids
Even countries or organisations that agree on the use of puberty blockers for trans children might have quite different guidelines around their use. Even when they were more routinely used in NHS England (if "routinely" is an appropriate adjective for the tiny minority of referred patients who reached the end of the waiting list) I don't believe they were ever licenced for such use (correct me if I'm wrong) which is itself a negative (though not a fatal one: many epilepsy medicines are not licenced in children but yet used if an expert feels appropriate). I don't think "support/don't support" binary is appropriate for what is a nuanced medical decision.
What those US organisations are really saying is where the government can go stick itself, interfering with clinical choices for political ends, and that is ultimately are more binary argument that what the consensus is on the evidence for any one particular therapy. Wikipedia is not a political football, so I'm not particularly impressed by "Press release in response to Senator Stupid's latest law proposal" as any kind of MEDRS source. It is a political source. -- Colin°Talk 16:37, 31 March 2024 (UTC)
I know your perspective but I feel like you have to consider that a statement to the effect of "it would be wrong to legislate against treatment of a condition" isn't the same as an endorsement of a specific common component of said treatment. If the source just mentioned puberty blockers I'd have no problem, and again I don't think the statement is even wrong. Would it be a fair compromise to include three organizations for which I found sources, assuming you don't object to them, and include the other two with a [citation needed] tag for a given period? XeCyranium (talk) 01:20, 2 April 2024 (UTC)
I'd be okay with that if you included them with a [better source needed] tag instead. Loki (talk) 02:35, 2 April 2024 (UTC)
I included the ACOG and ACP sources but upon further looking into the AAFP I'm not sure if they actually do have practice guidelines on puberty blockers. The source I previously provided was only their coverage of the Endocrine Society's recommendations, but carries a disclaimer that it is not an endorsement from the AAFP. XeCyranium (talk) 23:46, 9 April 2024 (UTC)

The lead and highlighting countries

Since there is dispute over removing it, I figure we should strike the current mention of the American and Australian medical bodies from the lead. My main reason for this is that we have multiple other countries that are included in the relevant section which we don't mention in the lead. Now one might say the solution is to add every country to the lead but at that point I think it becomes less a lead and more just a retreading of the section in question. XeCyranium (talk) 01:34, 24 March 2024 (UTC)

I feel I should also bring up [4] which I originally assumed was reverted by mistake to also reinsert the lead as it was. user:LokiTheLiar did you mean to continue to revert this edit? It seems like blatant WP:SYNTH to me, the source makes zero mention of Finland. XeCyranium (talk) 01:44, 24 March 2024 (UTC)
That was indeed a mistake. I agree the AAP source there is WP:SYNTH but not "On the other hand," as the source for the Finnish Ministry explicitly makes the comparison. Loki (talk) 01:49, 24 March 2024 (UTC)
I'd have no problem with saying that, the language itself didn't bother me it was the random American tidbit. XeCyranium (talk) 01:53, 24 March 2024 (UTC)
I'm not really sure where else to put this, but I'll attach this to concerns about naming individual, country-specific organizations and laws in the lead.
MEDORG doesn't actually talk about "international organizations". What the rest of the guideline means when it talks about "national and international expert bodies" is pretty much:
WPATH and Endocrine would fall under that last point. So would most (but not all) of the organizations listed in https://glaad.org/medical-association-statements-supporting-trans-youth-healthcare-and-against-discriminatory/ We usually understand "expert" as excluding political and outright quack organizations.
But: Just because we could create a laundry list of organizations that support caring for trans kids, or even that specifically mention support for using puberty blockers (e.g., the Pediatric Endocrine Society) doesn't mean that we actually should have such a list in this article at all (cf. Joe Biden presidential campaign endorsements vs Joe Biden), or that we should name-drop our favorites at the top of the article.
If we are treating this as primarily a medical article, the lead should usually contain straightforward factual statements on points such as:
  • what it is (e.g., drug class and how many different ones there are),
  • what it's used for,
  • how it works,
  • what the side effects or other problems are, and
  • what the history is (e.g., discovery, regulatory approval, availability).
For example: Antibiotics are drugs used for bacterial infections, they kill or at least stop further growth of bacteria, you might end up with diarrhea or other problems, we're all a bit worried about antibiotic resistance, and the discovery of antibiotics has literally saved millions of lives.
When I look at the lead that we have for puberty blockers now, I don't see the subject of this article being treated like a normal medical treatment. I see a strenuous "marketing" effort that leaves me with the feeling that there's something suspicious here. I'm being told that all the cool organizations endorse this treatment, and that we're under attack in all these states. (Oh, and those kids with precocious puberty don't matter, even though there are probably more kids with PP than kids taking puberty blockers as part of trans care, which is doubtless doubly discouraging for anyone trying to help a Kindergartner manage her menstrual period.) WhatamIdoing (talk) 03:09, 31 March 2024 (UTC)
Do we have any stats on how many are using these drugs for precocious puberty vs gender affirming? This page is not handling well the different uses of these drugs. For example, the page mentions this source wrt "women who took Lupron in order to grow taller" which appears to be an off label use. And I don't think our article reports this non-MEDRS source correctly, as the adverse effect reports are for the drug full stop, not one particular use. I think there is a danger we report on effects/side-effects for one patient group (e.g. v young children) or another (adolescents) and confuse the reader about which is relevant. And I suspect historically that's been the intention in this field, in that the safety profile for precocious puberty has been assumed for teenagers.
I agree the page is overloaded with legal and political stuff which are NEWS and less encyclopaedic than the medical aspects. -- Colin°Talk 09:54, 3 April 2024 (UTC)
This sentence: The NICE review has been criticized by WPATH and EPATH for excluding studies combining puberty blockers and hormone replacement therapy and by parents of transgender youth for excluding evidence of its safety when used by cisgender youth undergoing precocious puberty. performs exactly that conflation. Precocious puberty lacks the psychological element that is the centrepiece of gender dysphoria, and the concern of Cass is the "unknown impacts on development, maturation and cognition if a child or young person is not exposed to the physical, psychological, physiological, neurochemical and sexual changes that accompany adolescent hormone surges".[5]
Precocious puberty is a separate condition, with a separate treatment regimen, and it cannot be assumed that safety and efficacy in one treatment context transfers to the other. Barnards.tar.gz (talk) 16:49, 5 April 2024 (UTC)
Efficacy, definitely, since the desired treatment outcome is different. (Or rather, the studies that say GnRH blockers work to prevent puberty are transferable but can't be taken to say that preventing puberty in trans kids improves outcomes.) But that's not what the quote you're talking about criticizes.
For safety, though, it doesn't make any sense to say someone is going to have more bone problems because they're trans. It's the same medication in very similar patients. Loki (talk) 20:26, 5 April 2024 (UTC)
The patients may be physically very similar but they are certainly not psychologically very similar, and the concerns raised by Cass and others are around the impact on cognitive development. Is the treatment really safe if it blocks psychosexual development, which is intertwined with identity development? This is not an issue in cases of precocious puberty, but it’s the very heart of the issue in cases of gender dysphoria. Then there’s the issue of blocking the development of mature decision-making abilities which are relied upon once the “time to think” is up.
So, it does not follow that the treatment being safe for precocious puberty makes it safe for use in children with radically different psychological symptoms.
Barnards.tar.gz (talk) 22:46, 5 April 2024 (UTC)
This sort of suggests that you (or Cass) would agree with YFNS that instead of puberty blockers, doctors should just directly prescribe HRT. But I at least very much doubt that Cass would agree with that, which suggests that what they say about just being concerned about delaying puberty at all is not really the issue.
I would say I don't have a source for this opinion, but I kind of do, since this is more-or-less what WPATH means by The selected studies by NICE only focused on the effects of puberty blockers, therefore studies that evaluated a combination of blockers, hormones, and/or surgeries were excluded. Loki (talk) 06:41, 6 April 2024 (UTC)
I’m very confused as to why you would think that I or Cass would come to that conclusion. What I’m saying is that assuming the effects of a drug on one population will be seen in a different population is invalid. Barnards.tar.gz (talk) 07:34, 6 April 2024 (UTC)
Looking at it from general principles, the main "physical" differences are likely to be due to the length of time on the drugs and the developmental stage the brain's in. Taking any hormone starting at age 3, and staying on it for 7 years, is likely to produce different effects than taking that same hormone starting at age 10 or 11, and staying on it for 12 to 24 months. Usually, you'd expect cumulative damage (e.g., bone loss) to be worse the longer you take a drug, but some effects only appear if the drug is taken during particular developmental stages or in combination with some other event (e.g., another drug or a comorbidity). We can't be certain that the drug side effects will be the same in these two groups, but IMO it's not entirely reasonable to write the article from the POV that, because it's unknown, then short-term use in older kids has a significant probability of having worse side effects than long-term use in little kids.
For this article, therefore, I suggest that we give the facts (e.g., the research is mostly done in younger kids with PP instead of older kids with TGD) without overemphasizing uncertainty or research limitations. WhatamIdoing (talk) 00:54, 13 April 2024 (UTC)

Overall article structure

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

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

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

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

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

Updates to UK section

I don’t want to get involved in editing a medical article. But I think the UK section of this article should be updated to say (a) that private clinics may have trouble with the regulator if they prescribe puberty blockers [6], and (b) that the Scottish Sandyford Clinic has announced that it has ‘paused’ prescribing puberty blockers [7]. Sweet6970 (talk) 16:56, 18 April 2024 (UTC)

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

Cass Review

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

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

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

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

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

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

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

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

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

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

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

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

Consensus-based vs evidence-based

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

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

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

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

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

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

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

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

3. From the Taylor/Hewitt systematic review of guidelines[8]:

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

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

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

We should not ignore international consensus on this issue because of one study complaining about it. Loki (talk) 15:12, 17 April 2024 (UTC)
There is no international consensus, there are a multiplicity of viewpoints, with the centre of gravity of one cluster being WPATH and the centre of gravity of the other cluster being the European nations detailed already in the article. When we have a study (of the highest quality) suggesting that "the international consensus" is only "apparent consensus" due to circular reasoning, and that it is not as evidence-based as it claims, we cannot treat it as the only game in town. Barnards.tar.gz (talk) 16:16, 17 April 2024 (UTC)
It's not on the basis of one study complaining about it, though their complaints are entirely consistent with the reason MEDRS gives low weight to non-evidence-based opinions. The highest form of evidence for efficacy and safety comes from systematic reviews. Expert opinion is one of the lowest forms. In wiki voice we absolutely should state what these reviews have found, wrt what evidence there is and isn't. We need to say that some organisations disagree but we can only put their opinions as opinions. The lead currently gives enormous weight to spelling out which US organisations have published press releases, even if many of those organisations are not themselves involved in creating such guidelines and so are merely affirming "what he said".
We have first class sources saying that some organisations guidelines are non-evidence based. Which is fine if that's the approach they want to take. But we can't invent facts just because we wish it were otherwise. There are aspects of puberty blockers for which there is no good evidence they help, in wikivoice, and there are aspects for which there is modest evidence they harm. Claims by some organisations that they think there is evidence need to be backed up with their own systematic review that says so, because press releases don't trump that.
Per WP:MEDSAY we shouldn't restrict the wiki-voice facts about puberty blocker evidence to be "Cass Review stated that". For example, when we have systematic reviews that a drug is effective for focal epilepsy but not effective for migraine, we simply state that, without reference to where or how that information was arrived at. Time we did the same for puberty blockers. That isn't to say we ignore the controversy. -- Colin°Talk 11:37, 20 April 2024 (UTC)
There's one thing above systematic reviews in (one of) the pyramids in WP:MEDASSESS and that's "clinical practice guidelines". Clinical practice guidelines have not changed because of the Cass Review outside of the UK, and international clinical practice guidelines are not likely to change.
Furthermore, WP:MEDSCI says we should summarize scientific consensus and so far the scientific consensus on puberty blockers does not appear to be changing.
I agree it's strange that a series of major systematic reviews do not appear to be changing the overall scientific consensus on puberty blockers yet. But it's ultimately the consensus that we cover here, not any individual study, no matter how strong it may appear to us. And it's not like this would be the only time this has happened, either. In our article on masking for COVID we mention that Cochrane review that didn't find evidence of effectiveness... as one line, and then follow up with a line criticizing it. (Admittedly, this is partly because there are tons of systematic reviews in this area, but still.) Loki (talk) 03:03, 21 April 2024 (UTC)
Also from WP:MEDORG: Guidelines do not always correspond to best evidence, but instead of omitting them, reference the scientific literature and explain how it may differ from the guidelines.
Which is exactly what we should be doing here: not omitting the WPATH guidelines, but also explaining how they differ from the scientific literature.
Also, the phrase the overall scientific consensus is problematic here.
  • Firstly, there is no gold-standard source telling us what the (singular) overall scientific consensus is.
  • Secondly, I am guessing you are treating the WPATH (and WPATH-derived) guidelines as the yardstick of consensus - but we have now seen numerous reasons why that consensus may be flawed or illusory.
  • Thirdly, "consensus" and "evidence" and "science" are distinct terms of art in this context, which must not be conflated. As an illustration, the new German guidelines under development[9] are an "S2k-level" guideline. What does that mean? It's a German (AWMF) schema for positioning guideline reliability:[10]
S2K guidelines: S2K guidelines are developed by a committee of specialists in the medical field in question. The recommendations made are consensus-based. Because medical information isn’t systematically collected and assessed here either, the information that the recommendations are based on isn’t very reliable.
Figure 1 in this article explains the difference between consensus-based guidelines and evidence-based guidelines - the latter being needed to reach the higher level of an S3 guideline.
Needless to say, just because a group of doctors have reached consensus on a position, that doesn't mean (a) that all doctors agree with that position, or (b) that the position is based on scientific evidence. Medical reversal is a thing. In fact, WPATH is not primarily a scientific organization. It is a professional association. No doubt many of their members do conduct and publish scientific research, but as an organization it also seeks to further the interests of its own members, meaning it has one foot outside the domain of science. Therefore, even if WPATH represented universal medical consensus amongst doctors (it does not), this would not translate directly to scientific consensus. Barnards.tar.gz (talk) 09:12, 21 April 2024 (UTC)
Loki, what happens to a pyramid when the blocks below are removed? It falls down. The pyramid on the left, with clinical guidelines above meta-analysis and systematic reviews is drawn on the assumption that those guidelines are built on top of them. We now have a serious review of those guidelines PMID 38594049 and PMID 38594048 which clearly exposes that they are not. It's a pyramid for a reason, Loki.
There are three separate issues here. What the science says about the evidence, and what various groups declare to be recommended practice and what in fact occurs in the field (which sometimes is discovered to be way below standard). For the first, a systematic review, looking at all the studies in that area, grading them, and producing a scientifically sound conclusion is our best source. Often the evidence and the guidelines are gloriously in sync but here they are not and that isn't just editor opinion but something we also have the highest possible source for.
For example, in the UK our healthcare uses different metrics than the US to recommend for very expensive treatments (like the latest drugs). This can mean different treatments are recommended than in the US and that affects our clinical guidelines. Or the US may take a more "don't want to get sued" approach which means their guidelines include far more tests "just in case" then in the UK where wasting money is a concern. So guidelines can differ from the evidence base for various reasons. Sadly also sometimes professional or supposedly grass-roots bodies can come under the influence of those who do not care for the evidence but have other priorities. -- Colin°Talk 09:56, 21 April 2024 (UTC)
Adding a new source - statement from ESCAP strongly endorsing the findings of the NICE and Zepf reviews and recommending psychological intervention as a first line treatment.
https://link.springer.com/article/10.1007/s00787-024-02440-8
ESCAP calls for healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psychosocial effects and, therefore, to adhere to the "primum-nil-nocere" (first, do no harm) principle.
Void if removed (talk) 20:28, 29 April 2024 (UTC)
Adding another source - position statement from the Royal College of GPs, endorsing the Cass Review: https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care
GPs are advised against:
Prescribing puberty blockers for a patient aged under 18, even on a shared care basis, given the concerns about the evidence base in this area as well as the specialist expertise required to monitor dosage and side effects. The Cass Review1 notes that ‘the Review has already advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol. This has been taken forward by NHSE and the National Institute for Health and Care Research (NIHR)’ and that ‘if an individual were to have taken puberty blockers outside the study, their eligibility may be affected’. This precludes GPs from ever prescribing puberty blockers, excepting any GPs working on clinical trials in this area.
Void if removed (talk) 14:07, 1 May 2024 (UTC)

Culture wars, article split suggestion

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

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

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

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

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

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

Public opinion

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

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

Timing

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

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

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

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

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

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

Summary

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

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

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

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

This is a great summary of everything! For the Dutch protocol, the diagnosis would either have been 'gender identity disorder' (per the DSM-IV-TR) or 'transsexualism' (per ICD-10). I would need to check if fertility counseling was a part of the original protocol, but per the 2017 Dutch guidelines it is deemed necessary before PBs and (again) before GAHT. The official first version of the Dutch protocol was published in 2006 and probably goes into more depth than I can do here.
It may be interesting to add another column on the current Dutch guidelines: the minimum age of 12 was changed to Tanner stage 2G/2M (though a retrospective study found that no one actually got onto PBs before 13, IIRC, with the average of getting blockers being around 14.5) and children were allowed to get onto GAHT at age 15 if they had their puberty suppressed for a longer amount of time (not sure about what amount of time we're talking about, but probably longer than a year).
The Finnish guidelines can be found in an English document at the site of COHERE Finland. It stresses that other mental health issues need to be tackled before adolescents can be referred to one of the two Finnish GID clinics.
Again, great work! I think a table can really clarify the differences between guidelines.
PS: Sorry for not providing any links. I can't access my laptop atm. I'll look if I can add them later :) Cixous (talk) 15:13, 14 May 2024 (UTC)
Is the "official" Dutch (whether 2006 or 2017) something like a government regulation, or is it a more independent industry thing? I guess I'm asking whether it's more like an NHS rule (the public health system isn't allowed to deviate from it) or more like WPATH's SOC (not really binding on anyone). WhatamIdoing (talk) 23:03, 14 May 2024 (UTC)
If I am correct, the original protocol (2006) was published in a European Proceedings of Endocrinology journal (or sth to that effect). Back in the day, only VUmc had a GID clinic, so you might extrapolate that it was simply used by one clinic and not 'binding'. The 2017 guidelines, however, was written in a context where multiple providers had emerged and/or started to emerge (up to the point that two extra dedicated hospital centres have been opened for GID treatments for minors). The latter was published by the Ministery of Health, Wellfare and Sport and makes stringent recommendations about the minimal requirements for caregivers and surgeons (it's a collaborative guideline created by multiple Dutch health bodies), so that one is binding Cixous (talk) 06:21, 15 May 2024 (UTC)
I think you should reference this systematic review, which has essentially done all this work (see eg. table 1) and is a MEDRS.
https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326500 Void if removed (talk) 08:56, 15 May 2024 (UTC)
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