Talk:Puberty blocker/Archive 5

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Use in post-pubescent people

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

[1] offers this: In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of supressing the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones.

(It’s an odd source as it is based on an interview with Cass but doesn’t give any direct quotes from Cass; parts give the impression of being paraphrased or editorialised). Barnards.tar.gz (talk) 19:17, 8 May 2024 (UTC)

Thanks. That sounds like a bureaucratic reason rather than a biological one. WhatamIdoing (talk) 20:43, 8 May 2024 (UTC)

Indeed. But there are still gender-affirming outcomes even from late prescription of puberty blockers. The suppression of testosterone in males will reduce facial hair growth, and the suppression of estrogen in females will reduce or stop menstruation. Also, puberty and sex-specific development isn’t necessarily finished by 15. Barnards.tar.gz (talk) 21:14, 8 May 2024 (UTC)

This relates to another point that concerns me in this article: we currently cite Horton to say that "RCTs are widely considered unfeasible and unethical for transgender youth due to the fact those in the control group would have to be denied treatment".

I think this sets up Horton (and others) for ridicule, because control groups don't have to be no-treatment control groups, and eventually someone's going to notice this. One could have, e.g., a randomized controlled trial in which half the older teens get puberty blockers and half get slightly earlier access to cross-sex hormones. One could also have a trial in which younger kids are randomized to puberty blockers first and other mental health problems second vs the other way around, or starting at Tanner stage 2 vs 3 (what one source calls "complete absence of adult sexual function" is expected with the first, at least in trans women).

In fact, Horton quotes one saying "many would consider a trial where the control group is withheld treatment unethical", and I think we are misrepresenting the source by changing that "where" (as in, "if") into a "because it always means". I'm going to see if I can make this alleged fact somewhat more closely align with the cited source. WhatamIdoing (talk) 05:36, 9 May 2024 (UTC)

Or we could just drop Horton from this section, in the same way as I wouldn't quote Nicole Kidman (to pick an entirely random name) on the ethics of randomised controlled trials in any patient group. Horton has an opinion, but their expertise in societal matters and obvious personal interest in the topic seems to have elevated them to the point where we are citing them as though they are an authority on medical trial design (on the Cass Review talk page, they were argued for on the basis that we didn't at the time have any other peer reviewed criticism, which is a weak argument). See profile where they may merit quote on e.g. how or whether to include parents in the decision making process. The article focuses perhaps too much now on the NICE review which has been superseded by the York one commissioned by Cass. That review used an alternate grading scheme that doesn't have the criticism that GRADE has, making all this stuff about GRADE moot. The overall summary this section/paragraph should leave is that multiple systematic reviews over the years have complained that the evidence quality in this area is very poor. -- Colin°^Talk 08:15, 9 May 2024 (UTC)

Horton cites others for this point, so I don't think that we're relying entirely on Horton for the claim. WhatamIdoing (talk) 16:52, 9 May 2024 (UTC)

I dug into those citations over at the Cass Review talk. They're more equivocal than presented here, and one is a self-citation. Void if removed (talk) 17:26, 9 May 2024 (UTC)

And we've had a discussion about poor citations already! The first citation describes a "withholding" scenario for a treatment that works. It is kind of a chicken and egg problem in that if the current studies aren't, in some people's opinion, strong enough to show it works. Why are we claiming it works and so we can't possible do more studies? At what point does our possibly overconfidence prevent us becoming more realistically confident? The second citation is a guest editorial, which we would regard as an opinion piece. Horton's paper doesn't admit to being an opinion piece, but it is hard to read it as anything other than that, dressed up in fancy writing.

Anyway, I don't think you'd be impressed if my source was the Daily Mail and I countered your objections by saying the Daily Mail cited other sources. -- Colin°^Talk 17:39, 9 May 2024 (UTC)

I think that whole section is an issue. "widely considered infeasible and unethical for transgender youth" is a strong claim in wikivoice, and the citation is basically WP:RSOPINION and likely good only for an attributed opinion, if Horton's opinion is considered WP:DUE.

Weasel words in the source like "many would consider" don't inspire confidence.

In fact if you dig into the actual citations for claims like this, what they actually say is that RCTs are considered unethical in situations where there is good evidence a treatment works, and thus denying it to a control group would be unethical. The whole point of this current situation is there isn't good evidence the treatment works, nor a clear consensus on what it is even being used for, and so that argument doesn't actually apply. Void if removed (talk) 08:33, 9 May 2024 (UTC)

That's true but as me and WAID and one of the systematic reviews suggested, there are ways of doing an RCT that doesn't deny anyone a treatment that is known to be beneficial. Most European countries have long waiting lists for treatment in this area and nobody is utilising that as a control group. Or to use gender clinics in different countries as groups for comparison.

Plus it is rather a strawman because there are other flaws in the trials beyond their lack of control. Not least of which is that the founding trials are really old at a time when clinics got an equal small number of children and adolescents mostly AMAB. Compared with huge numbers of mostly AFAB adolescents with multiple other issues. And if you read the papers on the Dutch approach, they explicitly guard that patients must "have no serious psychosocial problems interfering with the diagnostic assessment or treatment". Something I think the Dutch team commented on in their response to the Cass review which was mostly "We do it like this anyway". Regardless of the medical facts about puberty blockers, there were clearly issues with how the London team were going about things, which have been discussed in a book on the clinic and in many other venues. Having a waiting list longer than puberty, as is the case, wasn't working. -- Colin°^Talk 16:18, 9 May 2024 (UTC)

Perhaps we could dedicate a specific section to discussions regarding study design from various perspectives, including a bioethical one. For instance, a name I've seen floating around a lot in the literature is S. Giordano, a bioethicist at Manchester University (who was, among other things, cited in de Vries et al. 2011). I'm not per se against the inclusion of Horton, but I agree that multiple sources with a different point of view can show the discussion on study design is much more nuanced than it is often portrayed (as Colin illustrates above quite nicely; control trials don't have to mean you deny another group treatment. I believe there are actually studies in the making which use people on the waiting lists as a control group, though I would need to double-check that).

PS: I can confirm what Colin says in his reaction. A large part of the VUmc response was about lauding the Cass Review for recommending extra mental health interventions. The 2017 report by the Dutch Ministery of Health (cited by this page, actually) specifically states that one of the demands that ought to be met before puberty suppression is the lack of psychological comorbidities (or, if they cannot be easily treated, the lack of severe psychological comorbidities). Van der Loos et al. (2023, p. 405, figure 5) shows that the time between the first appointment and puberty suppression varies each year, but is, modally speaking, roughly around the one year mark.

PPS: Just wanted to say that we should look out with claims like 'absence of sexual function' due to puberty suppression. One source may have put it that way, but we can't really say anything conclusive about that. Puberty suppression in trans women may lead to less penile tissue, which may preclude trans women from having penile-inversion vaginoplasty. Colonovaginoplasty does have a higher complication rate (I don't know if that applies to peritoneal pull-through vaginoplasty as well). When it comes to sexual functioning, however, it is not known if it impacts sexual functioning as much as some sources claim. The evidence on this is pretty scarce, though it seems to point into the direction that it doesn't have an enormous impact. The best thing we can do now, is hope for more data and thorough meta-analyses. Cixous (talk) 18:18, 9 May 2024 (UTC)

In re "absence of sexual function", it may well be understudied, and therefore to have scant scientific evidence, but the leaked documents quote Marci Bowers (WPATH’s president) as saying "To date, I’m unaware of an individual claiming ability to orgasm when they were blocked at Tanner 2."[2]

Have you seen any source saying this isn't a common problem? Or that it isn't lifelong? WhatamIdoing (talk) 18:35, 9 May 2024 (UTC)

In terms of finding sources, has anyone seen an informed consent document (or information about one) for puberty blockers?

For example, if your kid has leukemia and needs chemotherapy, (in the US) you are given pages of information about the drugs, including both short-term risks (e.g., infections) and also long-term side effects, such as damage to most major bodily systems, including heart, kidneys, lungs, liver, and brain, as well as a significant risk of irreversible total sterility. The choice isn't that hard (either he gets these drugs and maybe I won't have grandkids, or he doesn't take these drugs and definitely I won't have grandkids, because he'll die before then), but it is fully disclosed by both the drug manufacturer and the individual providers/clinics, because the alternative is an endless series of lawsuits over lack of informed consent.

Is there anything similar for puberty blockers? Whatever goes into the informed consent process could make a reasonable basis for organizing the ==Adverse effects== section. WhatamIdoing (talk) 18:58, 9 May 2024 (UTC)

I've seen some lol, their adverse effects sections match up pretty closely with our own off the top of my head, though I don't believe I've seen them mention idiopathic intracranial hypertension (perhaps newer ones do).

I just found this one from Fenway health that seems fairly similar to the one my clinic uses (which I can't find online) [3] Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:43, 9 May 2024 (UTC)

Thanks for that; I found it helpful. A quick precis:

• Timing: It takes a while to see visible effects, puberty restarts after about six months off the drugs. No word about how many years it's safe to take these (could a non-binary person take them until old age?) and no mention of the usual length of time to take them.
• Long-term effects: height effect uncertain, long-term effects uncertain (and no examples of possible harms are given).
• Social risk: Someone might notice the kid isn't going through puberty.
• Fertility requires "complete biological puberty" but non-reproductive aspects of sexuality aren't mentioned.

WhatamIdoing (talk) 20:24, 9 May 2024 (UTC)

The problem with Bowers' statement is that it is not rooted in methodological observation. It might be true, but scientifically speaking we can't say that. I know of one abstract (van der Meulen et al., 2023) of a still unpublished study that compares the sexual functioning between late puberty suppression (T4/5) and early purberty suppression (T2/3) and purportedly found no difference between the two groups when it came to ability to orgasm. Obviously, we can't say much about the study yet, and there may be flaws (the p-value isn't fantastic, 37 participants isn't an awful lot, and we don't know if 'problems during sexual intercourse' stem from merely physiological concerns or if they have a psychological dimension etc.), but I'm willing to give more authority to an ESSM abstract than an individual's statement. Obviously, this doesn't mean this discussion is closed (again, one unpublished study doesn't say an awful lot); it merely means that there is more nuance to this all. Cixous (talk) 19:15, 9 May 2024 (UTC)

That link says that it was published on 6 July 2023. WhatamIdoing (talk) 19:26, 9 May 2024 (UTC)

Jup, the abstract was published on that date. The full study hasn't been in a journal (yet). Cixous (talk) 12:46, 10 May 2024 (UTC)

In fact if you dig into the actual citations for claims like this, what they actually say is that RCTs are considered unethical in situations where there is good evidence a treatment works, and thus denying it to a control group would be unethical. The whole point of this current situation is there isn't good evidence the treatment works, nor a clear consensus on what it is even being used for, and so that argument doesn't actually apply.

• Puberty blockers are prescribed instead of hormones because of the belief that it gives trans kids time to change their mind about transitioning while not causing them distress through incongruent puberty.
• Nobody disagrees that puberty blockers block puberty. They are prescribed to block puberty and we know they are effective for that. IE, there is clear consensus the treatment works for what it is prescribed for.

• For the record, I consider forcing trans kids to take blockers (which they usually don't actually want, it's just better than nothing) for years instead of giving them hormones to be deeply unethical - but in the context of transgender healthcare puberty blockers are a conservative treatment that clearly work for what they are prescribed for.

• We know incongruent puberty causes trans people distress and necessitates further medical procedures down the line. What exactly is ethical about forcing trans kids to go through incongruent puberty and irreversible changes because you want to record how much they'll suffer when there's a known method of preventing that?

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:12, 9 May 2024 (UTC)

This is probably off-topic, but I think the problem is the assumptions in "We know incongruent puberty causes trans people distress and necessitates further medical procedures down the line". What we actually know is that incongruent puberty causes some trans people varying amounts of distress and necessitates further medical procedures down the line for some of them.

We also know some other things, e.g., that sexual dysfunction and infertility causes some people varying amounts of distress and necessitates further medical procedures down the line for some of them. (We even know that these are risk factors for suicide.) We could ask: What exactly is ethical about risking sexual function and fertility, when there's a known method of preventing that?

What we don't know is: Which people will be more distressed and more harmed by which outcome? Some trans people (e.g., non-binary folks) might be okay with sex-congruent puberty and gutted by infertility. WhatamIdoing (talk) 21:02, 9 May 2024 (UTC)

We could ask: What exactly is ethical about risking sexual function and fertility, when there's a known method of preventing that?

Many many drugs impact fertility, we don't stop using them purely on that basis or prize it as the end all be all of a person's health. The simplest solution is to ask them if they're ok with going through puberty to preserve fertility and want to discuss fertility options (and state funding for fertility care for all). If somebody says they want to transition and are fine with being infertile, that's their body, they should not be forced through permanent changes of puberty they explicitly don't want because somebody else thinks they might want kids in future.

What we don't know is: Which people will be more distressed and more harmed by which outcome?

If we don't know, then respecting the patient's bodily autonomy and informed consent is a good place to start - those saying they'd prefer transition to fertility will probably be more distressed and harmed by being denied transition, those saying they'd prefer fertility preservation to transition can just do so. People shouldn't be denied a treatment for something definitely causing immediate distress because of the mere possibility something else will in future despite them being explicit they'd prefer transition over fertility. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:58, 9 May 2024 (UTC)

People shouldn't be denied a treatment for something definitely causing immediate distress because of the mere possibility something else will in future

This rule sounds sensible to me as a general principle, but I find that medical ethicists routinely disagree with me. Teenagers are not allowed to run certain genetic tests, no matter how distressed they are about the possibility of having Huntington's disease. Teenagers are also not allowed to get vasectomies or tubal ligations, no matter how certain they are that they will never want biological children.

informed consent is a good place to start

Can you have informed consent when the answer to "What is the long-term risk to fertility and sexual function, if I take this drug for five years and then stop?" is someone shrugging their shoulders, or saying that it's unethical to learn the answer to that question? WhatamIdoing (talk) 22:24, 9 May 2024 (UTC)

Can you have informed consent when the answer to "What is the long-term risk to fertility and sexual function, if I take this drug for five years and then stop?" is someone shrugging their shoulders

• Yes, though presumably it would be more than shrugging their shoulders. If those effects are medically unknown, part of informed consent is saying they're unknown. If somebody gives me a vial of unidentified liquid and says "I have no idea what this is, it might cure your headache it might kill you painfully", it would be bloody stupid for me to drink it but I wouldn't be making an uninformed choice. If a doctor says "if you take this for 5 years and stop we don't know what the state of your fertility could be" - that lack of information is the information that informs the consent.

or saying that it's unethical to learn the answer to that question?

• Please point me to who says trans healthcare research is unethical, I've yet to see anyone claim that. People have raised concerns about certain study designs, sure, but nobody says the research just shouldn't be done. The state of trans healthcare is an absolute shitshow, from lack of access to full denial of care, from the lack of longitudinal studies to known and unknown unknowns, not to mention the history of pathologization and enforcement of gender roles and stereotypes, but a large part of that is because the field is currently having to expend its energy dealing with concerted efforts by quacks to question whether trans people exist or should transition at all.

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:49, 9 May 2024 (UTC)

Nobody disagrees that puberty blockers block puberty.

Of course - the part there is no consensus about is why block puberty. It ranges from time to think, to alleviate distress, to enable passing better in adulthood. And so this is one thing that makes the evidence base for whether it even works as an intervention so weak - because there is inconsistent purpose, therefore inconsistent measurement of whether the outcome fulfilled any purpose. Void if removed (talk) 21:41, 9 May 2024 (UTC)

Yes, I think you're right. "It's effective" should be read as "It's effective for ____". To give an analogy, it's true that chemotherapy is effective – but not for headaches, depression, iron-deficiency anemia, hypertension, etc. We are agreed that puberty blockers are effective for blocking puberty, but I think what people want to know is more like are they effective for making teenagers less distressed, helping them make durable decisions, etc? WhatamIdoing (talk) 21:53, 9 May 2024 (UTC)

The purpose of blocking puberty is simple - to hold out hope the kid isn't trans while handling the possibility they at least might be. They've been painted as this radical intervention when their entire basis is "we think these kids might suddenly change their mind about being trans so instead of giving them HRT, we'll make them wait a few years - if they're cis they can restart puberty, if they're trans they can start HRT later but at least they didn't go through an incongruent puberty".

• time to think is the primary reason per the above. Whether they actually need that "time to think" is another question (and considering how many go from blockers to hormones, I think they don't), but if you are operating on the premise "the kids who say they're trans might not be so we can't give them HRT too young, but they might be so we can't do nothing" then it is the only solution.

• PBs can be understood as a weird relic of the pathologization era / the start of the depathologization era. In the pathologization era, trans kids would be put through conversion therapy and only allowed to transition as an adult. That was unethical, but doctors didn't want to let minors transition, so puberty blockers developed as a messy compromise between trans people/youth, parents, pathologizing doctors, and non-pathologizing doctors that nobody was completely happy with - that's why it's based on the conflicting premises "the kids know they're trans, respect them and let them transition" and "they might be wrong, so don't".

• to alleviate distress - somewhat, it's more so to prevent (worse) distress. Basically every systematic review of PBs has come to the same conclusion: "this doesn't seem to make dysphoria better as it remains mostly stable, but if untreated it would be expected to worsen so this could be evidence of efficacy".
• to enable passing better in adulthood - this is obvious, it's easier to pass if you didn't go through an incongruent puberty, but it would be true if you just gave the kid HRT

If you operate from the premise some kids are trans but you think a portion who say they are are wrong - PB's make sense.

If you operate from the premise trans kids aren't real, PB's are unethical.

If you operate from the premise trans kids are real and should have bodily autonomy, PB's are a better option than no transition. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:26, 9 May 2024 (UTC)

Here's what MEDRS say:

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

And these various aims have led to unclear evidence:

Included studies assessed different outcomes across various outcome domains and employed multiple different measures. Agreement about the primary aim and related core outcomes of puberty suppression in this population would help to ensure studies measure key outcomes and facilitate future aggregation of evidence.

Perhaps if there was clarity as to why puberty is being blocked and what constitutes a good outcome, then good evidence might exist as to whether it was actually working as intended. Void if removed (talk) 08:43, 10 May 2024 (UTC)

We've just had a major review that concluded the "time to think" rationale is unsupported by evidence. Nearly all the children progressed to cross-sex hormones, which is something that has been known for some time and even highlighted as "evidence" of the persistence of thinking among this group. If anything, the evidence is that going on puberty blockers reinforced the inevitability of a medical pathway. But of course, without control groups, the whole area is open to speculation. I think therefore we need to be careful to separate the rationales people have given for using puberty blockers, from the lack of evidence that they achieve that aim. -- Colin°^Talk 09:12, 10 May 2024 (UTC)

To be honest I think the fact that the majority of people on puberty blockers go on to CSH, doesn't counter the time to think rationale if it is difficult to get puberty blockers in the first place. For example in the UK where one is on a waiting list for years before recieving puberty blockers, the people who would have decided not to continue on to CSH would have just decided not to have puberty blockers. The waiting list effectively acts as the time to think that puberty blockers are meant to be used for, but it only works this way for people who don't want CSH. LunaHasArrived (talk) 10:53, 10 May 2024 (UTC)

This just means one has to be very careful when using this sort of data and that it doesn't necessarily disprove the time to think narrative. LunaHasArrived (talk) 10:55, 10 May 2024 (UTC)

It isn't really for you or me or YFNS or Void to judge whether or not they are working on this or that evidence. I'm saying we have a reliable source doubting this rationale is now nothing more than "Something people once thought might be true, and some people still claim even now we know it isn't". Criticism of the Time to Think concept is a pretty big issue. Even to the point of Time to Think (book) being named after it. The pattern of inevitability isn't restricted to GIDS but seen anywhere that uses them. -- Colin°^Talk 11:47, 10 May 2024 (UTC)

100%, I'm not saying puberty blockers do work or for what purpose they do work. I'm just saying that in a country where you wait years to get them, if there were people who would use them to decide whether or not to continue on to CSH, the waiting list filters them out anyway and isn't a fair sample of the idea. The evidence of 95% or whatever continuing just means that in the current way they're being implemented (wait list included) they are not giving people time to decide. LunaHasArrived (talk) 12:14, 10 May 2024 (UTC)

But what makes you think the review's conclusion on this "time to think" idea was reliant (or even looked at) UK data. The waiting list "filters out" argument is only relevant to the fairly recent explosion in teenage referrals. Most of the studies looked at are pretty old at a time when clinics had a patient or two per week! Colin°^Talk 12:37, 10 May 2024 (UTC)

Honestly speaking I would be really interested to read these reports but if these reports are 20+ years old I think one can easily see how times have changed over the years and the stats might not as accurate to the current patient profile as one would hope. LunaHasArrived (talk) 13:08, 10 May 2024 (UTC)

And a valid counter-hypothesis is that the time spent waiting for intervention fixates on it as a solution and cements it as a goal, preventing the "thinking" expected while increasing the distress until the "solution" is available. The more time invested waiting, the harder it is to change your mind, per the sunk cost fallacy. Without adequate research actually willing to ask the right questions its a wild stab in the dark as to which of these is more true, but assuming that the longer the wait, the more people who "would have" desisted will drop out is I think over simplified, especially in the current media climate.

And the fact is, for all its flaws, GIDS still had a more rigorous approach than private clinics and the informed consent model of the US where most of the recently touted research was performed. Void if removed (talk) 12:56, 10 May 2024 (UTC)

If you're mentioning the current media climate, why would anyone want to be seen as trans. Ignoring that though, the main point was that the evidence doesn't say "all people who take puberty blockers continue", just given the current medical frameworks and media climate that is what happens. I.e if one changed the medical frameworks (giving them out easier or any number of other changes), this could significantly change. LunaHasArrived (talk) 13:02, 10 May 2024 (UTC)

Of course extrapolating study findings more widely is something we leave to the experts. But the point is that if one's hypothesis is that if this approach gives time to think about one's gender and possibly reconsider going onto cross sex hormones, then one might reasonably expect a study looking at this therapy to demonstrate a good portion of the children do indeed reconsider. The absence of good evidence of that is a problem for those making the "time to think" claim, not a problem for those saying "well, where's your evidence?". -- Colin°^Talk 13:22, 10 May 2024 (UTC)

But the point is that if one's hypothesis is that if this approach gives time to think about one's gender and possibly reconsider going onto cross sex hormones, then one might reasonably expect a study looking at this therapy to demonstrate a good portion of the children do indeed reconsider.

Not necessarily, you are conflating "they are mandated time to think because others are worried they might change their mind" with "they need time to think because enough will change their mind". If the hypothesis is "a significant percentage of kids who say they're trans will change their mind given time", and the data shows "the majority don't change their mind given time", the hypothesis was wrong.

I think the key issue is almost everybody knows "time to think" is bullshit, but

• 1) from a non-pathologizing approach: if delaying their transition doesn't make them change their mind, why delay the transition in the first place is the obvious answer (as moved towards by WPATH SOC 8). But, the issue is parents who won't sign off to a 14 year old starting HRT are slightly more likely to allow them to take PB until 16 then decide (we must remember healthcare access for trans youth is entirely mediated by their parents' fears, concerns, and prejudices).
• 2) from a pathologizing approach: running on the assumption being transgender and transitioning are things to be avoided if possible, if the majority of kids who say they're trans and want to transition continue doing so after being made to wait in the hopes they'll change their mind, the problem is not enough are changing their mind as hoped.

But worth noting, international medical consensus is: 1) being transgender is not a pathology or a bad thing, 2) this applies to transgender youth too, and 3) attempts to convince trans people they're not trans is unethical and conversion therapy. So, the former holds more weight. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:48, 10 May 2024 (UTC)

Colin, Void, the idea that it's "cementing" a medical pathway relies on a pathologizing framework and relies on fundamental misunderstandings of how the care is provided.

I think you may not understand how the trans youth themselves view blockers - almost none actually want them, they're just a lesser evil. If you want to medically transition and take HRT, you are required to go through the "time to think" if your parent or doctor thinks you're too young.

The reason so many kids go from puberty blockers to hormones is they wanted to go on hormones in the first place and were told the best they could get is blockers. It's not a bunch of kids saying "I don't know my gender or if I want to take HRT, can I pause puberty to figure out", it's them saying "I know I'm trans and want to take HRT, if I have to do this bullshit waiting period until then I will, at least the incongruent puberty won't actively get worse".

If a trans kid is explicit they want to medically transition, and continues to be explicit they want to medically transition, and therefore signs up the delayed "time to think period" required of them to transition, it is mental gymnastics to arrive at the conclusion the waiting period they're forced to go through to transition is what's making them want to transition. The only way the "cementing" idea makes sense is if you handwave away the fact they all explicitly identify as transgender and explicitly want to transition because of some vague unfounded and unevidenced hope that they'll suddenly stop identifying as trans. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 18:23, 10 May 2024 (UTC)

Thinking back on all these discussions, it looks like the article should say that three reasons are given (e.g., the stories told to legislators and taxpayers):

• stabilize (not improve) GD-related distress
• time to think about whether you want cross-sex hormones
• make future passing easier if you pursue cross-sex hormones

The stories supportable by evidence are:

• it might not make GD worse
• if started early enough, it can contribute significantly to passing
• if started early enough, it has significant negative effects on adult sexual function
• if done long enough, it has significant negative effects on bone density

What's actually happening in the UK specifically is:

• teens can't go on CSH until they've done PB for a year, even if they have completed puberty, so it's a bureaucratic step for teens who have already decided to do CSH. Consequently, "time to think" is not easily measured in this population.

I think the place to present part of this in the article is under ==Medical uses==, "Puberty blockers are intended to allow patients more time..." We could follow that list of reasons with the fact that these rationales are only getting lip service in the research (which is not normal: usually, the rationale for treatment is the key outcome). WhatamIdoing (talk) 16:01, 10 May 2024 (UTC)

I broadly support this. I do think it might not make GD worse isn't the full story though - I don't think anyone suggested it could make it worse and it's prescribed to stop GD getting worse so "might not make it worse" is an inverse of what we know: "It doesn't make GD improve but possibly prevents it from worsening", as evidenced by the NICE and KIND reviews conclusions below.

Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance. It is plausible, however, that a lack of difference in scores from baseline to follow-up is the effect of GnRH analogues in children and adolescents with gender dysphoria, in whom the development of secondary sexual characteristics might be expected to be associated with an increased impact on gender dysphoria, depression, anxiety, anger and distress over time without treatment.[4]

Overall, based on the results of the previous studies presented here and discussed here, there is no solid evidence that GD in particular and mental health in general improve with the administration of PB and CSH in minors. An alternative and equally important interpretation for those affected could nevertheless be that an unchanged experience of GD and body (dis)satisfaction after PB administration already represents a relative treatment success: PB administration could possibly lead to a further clinical deterioration. by blocking the development of secondary sexual characteristics, which is experienced as stressful.[5] Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:58, 10 May 2024 (UTC)

The one study I read earlier this week said that just under 20% of the kids self-reported self-harm before PB and just over 30% of the kids self-reported self-harm after going on PB. The authors said they didn't believe that the +50% relative risk change they actually found was causal (they speculated that if they had had an untreated control group, it might have seen an equal or greater deterioriation). The story reminded me of the path to a good grade in freshman chemistry lab: Draw the curve, plot the points, and take the measurements. We always had a good story for why the results we got didn't line up with the results we thought we were supposed to get.

By the way, if nobody's suggesting that PBs can make mental health worse, then I suggest to you that the research community has too few menopausal women in it. Hormone changes always have the potential to make mental health worse, especially in the short term.

Anyway, for the purpose of article content, I don't think we should overstate this in either direction. It doesn't seem to improve mental health in the short term, and regardless of whether it's proven to the usual level (e.g., the level used to talk about mental health effects for the same drugs when they're used to treat prostate cancer), the community has rationalized the belief that it also doesn't hurt. "Mixed results" is a phrase we use in some other drug-related articles, and it might be useful here. WhatamIdoing (talk) 18:51, 10 May 2024 (UTC)

By the way, if nobody's suggesting that PBs can make mental health worse, then I suggest to you that the research community has too few menopausal women in it. Hormone changes always have the potential to make mental health worse, especially in the short term.

• We were discussing GD, not mental health as a whole. You listed it might not make GD worse and I said I do think "it might not make GD worse" isn't the full story though - I don't think anyone suggested it could make it worse and it's prescribed to stop GD getting worse. Gender dysphoria is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth. Short term effects on mental health notwithstanding, which I'm pretty sure we already mention in the article, I think the medical community is fairly confident blocking puberty does not worsen gender dysphoria.

I think we should stick to the reviews and "Mixed results" isn't descriptive enough. The NICE and KIND reviews are explicit "this doesn't seem to actively improve or worsen GD or mental health - but those are expected to get worse if untreated so they could be working as intended - but we can't say that for sure" Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:12, 10 May 2024 (UTC)

I don't think that dividing the world into "pathologizing" and "not pathologizing" (or whatever the word is for that) is helpful and comes from activists finding labels to throw at people. For example, "the assumption being transgender and transitioning are things to be avoided if possible" is loaded with the suggestion that anyone thinking that a psychologist might do a bit of their actual job, rather than question why this young person wasn't directly referred to endocrinology the moment the word "trans" crossed their lips, is a transphobic conversion practitioner. It over simplifies the argument make e.g. by Cass who explicitly says they think transition is appropriate and the best thing for some people.

Here's an example: engagement. Who people declare a wish to marry, symbolise this with rings or whatever, and have a period where they have time to think, time to plan and time for their friends to go "Noooooooo!". Nobody is suggesting that marriage is the worst possible outcome to be avoided at all costs. The opposite in fact. It is a recognition that for some couples marriage to each other might not be appropriate. The Dutch protocol that came up with this idea also had the idea that it isn't an appropriate path for everyone who turns up at the clinic. Cass repeats that. Why is accepting that "pathologizing"?

Btw, I think we need to be careful to stick to our sources wrt working out the intentions and evidences. Our sources declare why e.g. time to think is a feature of most protocols. And we have sources debunking that idea. Whether anyone here thinks that debunking might have flaws or not isn't really our concern. And I don't really understand the focus on the peculiar UK use of PB when the reviews looking at them looked at all clinics reporting studies from all over the world. -- Colin°^Talk 18:57, 10 May 2024 (UTC)

I don't think that dividing the world into "pathologizing" and "not pathologizing" (or whatever the word is for that) is helpful and comes from activists finding labels to throw at people. You may think it comes from activists, the World Health Organization and UN[6], the APA, and the scientific literature is all very clear it comes from the fact until about a decade or two ago "transgender identity is a pathology" was a widespread idea, and a harmful one everyone should move away from, and there's been global effort to do so.

For example, "the assumption being transgender and transitioning are things to be avoided if possible" is loaded with the suggestion that anyone thinking that a psychologist might do a bit of their actual job, rather than question why this young person wasn't directly referred to endocrinology the moment the word "trans" crossed their lips, is a transphobic conversion practitioner.

What does a psychologist might do a bit of their actual job actually mean? What is there actual job here? Mandating psychotherapy as a requirement to transition ended decades ago. You seem to be laboring under the misapprehension that if a kid says "I am trans and also have these mental health issues", affirming them means giving them HRT and saying they don't have mental health issues. It doesn't, it just means "identifying as trans" isn't considered a mental health issue - because it isn't. The assumption being transgender and transitioning are things to be avoided if possible - is not loaded with any suggestions, that assumption is just transphobic plain and simple.

It over simplifies the argument make e.g. by Cass who explicitly says they think transition is appropriate and the best thing for some people. - this argument would hold more weight if the pathologizing approach for decades had not been "we'll let some trans people transition only if trying to talk them out of it for years doesn't work". The rhetorical trick "transition is appropriate for some who want it" hides the real message "but we don't think it's appropriate for most who want it" Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:46, 10 May 2024 (UTC)

So here's a question (pun not intended): Are PBs for kids who are Questioning (sexuality and gender)? Or just for kids who are consistently, persistently, insistently trans? WhatamIdoing (talk) 02:04, 11 May 2024 (UTC)

In both theory and practice, they are only given to the latter in the hope they're the former.

To get prescribed puberty blockers, you have to have diagnosed gender dysphoria or gender incongruence. Both of those are defined by 1) insisting you are transgender 2) insisting you want to medically transition.

The original dutch protocol[7] was explicit they're given to 1) to prevent psychological trauma from the wrong puberty 2) making it easier to pass but also 3 as a very helpful diagnostic aid, as it allows the psychologist and the patient to discuss problems that possibly underlie the cross- gender identity or clarify potential gender confusion under less time pressure. It can be considered as ‘buying time’ to allow for an open exploration of the SR wish (8). They defined the requirements for this treatment as being the same as the 16-18 year old camp, which was (ii) suffering from life-long gender dysphoria that had increased around puberty, (iii) functioning psychologically stable, and (iv) supported by their environment.

So they only gave it to the kids who were really sure they wanted to transition, who they cleared as otherwise psychologically healthy per their diagnostic criteria, but still with the expectation that they were wrong and the "waiting time" would allow them change their minds. The conflict between hope they'll desist and reality they won't is exemplified with the quote: By starting with GnRHa their motivation for such exploration enhances and no irreversible changes have taken place if, as a result of the psychotherapeutic interventions, they would decide that SR is not what they need. However, until now, none of the patients who were selected for pubertal suppression has decided to stop taking GnRHa. On the contrary, they are usually very satisfied with the fact that the secondary sex characteristics of their biological sex did not develop further. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:38, 12 May 2024 (UTC)

Can we (realistically) source that? "These are only given to kids who are definitely already trans" (if true, etc.) would be a useful thing to state in the article. WhatamIdoing (talk) 00:18, 13 May 2024 (UTC)

I didn't say "definitely already trans", I said diagnosed with GD/GI, which in medical terms means the person went to a clinic and said "I consider myself different gender than assigned at birth and want to medically transition".

I don't think this is hard to source, the York review on PBs is about them in relation to adolescents experiencing gender dysphoria/incongruence and analyzed about 10,000 of them[8]

The WPATH soc 8's chapter 6 (Adolescents) provides a decent overview and says We recommend health care professionals use gonadotropin releasing hormone (gnrH) agonists to suppress endogenous sex hormones in eligible* transgender and gender diverse people for whom puberty blocking is indicated, it's statement 6.12 going into more details.[9]

The dutch protocol's requirements, per my other comments but summarized by the Cass review: Minimum age 12, life-long gender dysphoria increased around puberty, psychologically stable without serious comorbid psychiatric disorders that might interfere with the diagnostic process and family support ie they only gave it kids they were pretty sure already were trans.[10]

From the endocrine society[11]: We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment (Table 5), and are requesting treatment should initially undergo treatment to suppress pubertal development.

Here's another review starting with Increasingly, early adolescents who are transgender or gender diverse (TGD) are seeking gender-affirming healthcare services. Pediatric healthcare providers supported by professional guidelines are treating many of these children with gonadotropin-releasing hormone agonists (GnRHa), which reversibly block pubertal development, giving the child and their family more time in which to explore the possibility of medical transition. and the majority (71%) of participants in these studies required a diagnosis of gender dysphoria to qualify for puberty suppression and were administered medication during Tanner stages 2 through 4. [12]

What I'm trying to get at is statements in the lead such as Puberty blockers are used to delay the development of unwanted secondary sex characteristics in transgender children, so as to allow transgender youth more time to explore their gender identity. would be more appropriately Puberty blockers are prescribed to transgender early adolescents after Tanner Stage 2 to delay the development of unwanted secondary sex characteristics with the aims of preventing gender dysphoria from worsening, making it easier to pass in future, and giving the minor time to change their mind. The practice of perscribing puberty blockers for these purposes began in the 1990s in the Netherlands due to transgender youth suffering distress from incongruent puberty and having difficulty passing as they were required to wait until the ages of 16-18 to begin hormone therapy. The majority of youth who request blockers later request hormone therapy. We need to be clearer about why they're prescribed - the previous treatment for early adolescents who everybody involved agreed was obviously transgender and wanted to medically transition was to let them go through an incongruent puberty until the age of majority. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 02:30, 13 May 2024 (UTC)

"the assumption being transgender and transitioning are things to be avoided if possible" is not the most helpful framing in an article about a medical treatment, because most of the medical literature doesn't deal in the question of whether someone has a certain identity, but rather in terms of whether someone has gender dysphoria. The framework that research operates in is not "transition is to be avoided if possible", it's "gender dysphoria is to be avoided if possible" - and I think there is universal agreement that dysphoria is a bad thing. Cass, for example, makes no statement on whether a trans identity is a desirable or undesirable outcome, and seems to view that as out of her remit. The goal of eliminating gender dysphoria gets confused as being "the elimination of trans identity, and thence trans people", causing horror and accusations of conversion therapy. Barnards.tar.gz (talk) 14:32, 11 May 2024 (UTC)

The definition of GD is 1) being explicit you are transgender and 2) explicitly wanting to transition. To transition, you are required to get a GD diagnosis. GD replaced transsexualism/gender identity disorder as the diagnosis because the medical establishment needed to provide transition care without framing being trans as the disorder. Trying to separate the frameworks of "how to treat GD" and "how to treat trans people" is like trying to unmix paint.

There is no way to treat GD that is not transition. There is literally no evidence, after ~100 years of looking from thousands of medical professionals and millions upon millions poured into research, of any other treatment for those suffering it than letting them transition. The goal of eliminating gender dysphoria without transition is the goal of making those who want to transition stop wanting to transition, which is conversion therapy, plain and simple. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:52, 12 May 2024 (UTC)

Is this working from a definition of trans that is "AMAB kid is definitely a girl and has been her whole life and would like a body to match", but excluding some non-binary and gender fluid folks (i.e., the ones who aren't interested in related medical interventions)? WhatamIdoing (talk) 00:23, 13 May 2024 (UTC)

No, this isn't working from a definition of trans at all. "Gender dysphoric people" is medical speak for "the subset of trans people who want to medically transition" per part 2 of the above definition. You can be trans and not want to transition, but if you want to transition you are required to get a GD/GI diagnosis due to insurance, bureaucracy, and the medical system, for better or worse, requiring a code for what you're being treated for. I should have said Trying to separate the frameworks of "how to treat GD" and "how to treat trans people who want to medically transition" is like trying to unmix paint. Doctor's don't give people HRT for the common cold, so as much as they don't want to pathologize 1) trans people or 2) the subset who want medical transition, they give it the second for the code "GD".

However, that being said, depending on where you live you can require a GD diagnosis to change your documentation even if you don't want to medically transition (or can't). In which case, treatment is still individualized these days, you are not required to transition a certain way for a GD diagnosis - you can forego hormones, or surgery, or specific surgeries and not others, and etc - and you are not required to be a "certain kind of trans person" for a GD diagnosis (such as the old standard of the "true transsexual" which required being attracted only to men, desiring to assimilate, wanting bottom surgery, and successfully fulfilling gender stereotypes such as wearing only dresses).

When I say There is no way to treat GD that is not transition, that is because it is equivalent to there is no way to treat [insisting you are transgender and want to medically transition] that is not transition, at least ethically. Because, for over 100 years, doctor's have realized when somebody says "I'm trans and want to medically transition", they will not stop (of their own free will) until you aid their transition because every alternative has been tried. Conversion therapy from religious to secular and talk to electroshock. Anti-depressants and anti-psychotics. Asylums and Applied Behavioral Analysis. If somebody insists they want to medically transition, no treatment has been devised, despite considerable effort, that will change their mind. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 03:04, 13 May 2024 (UTC)

1) There is subtle but significant slippage when we paraphrase "having GD" as "being transgender". An ontological element has crept in which is not the focus of the medical literature. You said in another comment that GD is "medical speak" - yes, it is, and in a medical article, it's important that we use medical terminology.

2) The idea that There is no way to treat GD that is not transition cannot possibly be true, unless desistance never occurs (but clearly it does). Indeed, this is the very heart of the matter: we don't know which kids will desist. For those that do, their GD may have been alleviated by some process that is not transition, even if that process amounts to doing nothing at all. Is desistance to be counted as conversion therapy?

This is the kind of problem that is all too easy to slip into if you treat GD as merely a medical billing codeword for "being transgender" - it denies the existence of the cohort of people for whom the condition is not a permanent one. Barnards.tar.gz (talk) 16:58, 13 May 2024 (UTC)

1) When the majority of MEDRS acknowledge "this is medical speak for this demographic because we're in an awkward place of acknowledging their health needs without classifying their existence as a disorder", we should too. The medical literature is very flat out about this and you are trying to unmix paint by appealing to MEDRS which agree the paint is mixed.

2) Please show RS that there is a treatment for GD other than transition. Insofar as there is any evidence of "desistance" - it shows that's only true for (at an overestimated maximum) 10%. If, we don't know which kids will desist, mandating the "treatment" that will be fine for 10% but cause 90% to suffer is self-evidently ridiculous. Desistance, for the record, is based on stats from Kenneth Zucker who treated trans and gender-noncomforming children (ie, not just those who identified as trans) and tried to convince them not to be gender noncomforming or trans at all, to prevent the trans kids from growing up trans and just in case the gender noncomforming kids might grow up trans - he explicitly put steering the kid away from identifying as trans and gender-noncomformity as a treatment goal. He is known for conversion therapy, specifically gender identity change efforts, ie the evidence of high "desistance" rates is a conversion therapist took kids who were trans/gender-noncomforming, put them all through conversion therapy in case they were trans, and then recorded "most didn't identify as trans" as evidence he was effective when that was true when they entered. In actual MEDRS, it is agreed the vast majority of kids who want to transition / consider themselves trans do not "desist"

This is the kind of problem that is all too easy to slip into if you treat GD as merely a medical billing codeword for "being transgender" - which is why I said it's the codeword for "being transgender and wanting to medically transition". it denies the existence of the cohort of people for whom the condition is not a permanent one. But what is the condition according to MEDRS? "identifying as transgender and wanting to medically transition". You can say "some of them might be wrong and or regret transitioning", sure, but the condition according to MEDRS remains the same.

If somebody desires medical transition, what is the treatment, ie the course of action that MEDRS agree is appropriate? For a while it was "try and convince them not to want that", which didn't work, so it became "try and convince them not to want that, then let them medically transition if it doesn't work", which didn't work especially well and still had ethical isues, so it became "help them medically transition with informed consent in accordance with their goals and without judgement", which has worked better and comes from taking human rights and medical ethics into account.

What's funny about this is as I was typing I realized: there actually is one other recognized semi-treatment for GD in adolescents that's not transition: PB and time to contemplate transition, which are given instead of HRT in the hopes the youth will "desist". Even then, if the "GD" (desire to medically transition) persists, it is recognized that nothing apart from transition would help - so we've come full circle to the medical system has been unable to treat "wanting to medically transition" successful in any way other than "letting them transition" or "making them wait a bit so they're sure they want to transition, without making them go through an incongruent puberty, and then letting them transition", which in either case is the same end treatment. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:50, 13 May 2024 (UTC)

The suggestion that desistance isn’t a real thing and is “based on stats from Kenneth Zucker” seems fringe. Barnards.tar.gz (talk) 20:49, 13 May 2024 (UTC)

When did I say it wasn't real? I said it's true for (at an overestimated maximum) 10%

“based on stats from Kenneth Zucker” seems fringe. - Kenneth Zucker has an article - you can see he's a FRINGE conversion therapist. You can check gender identity change efforts to find the same. And here are multiple sources (including systematic reviews) explaining how he coined the term desistance (a word borrowed in crimonology and pathologizing trans identities) and his studies claiming the majority of transgender youth "desist" were not supported by their own evidence and there's not even an agreed upon definition of desistance [13][14][15][16] [17] I'll quote the best source ( Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review)[18]:

• While a standard definition of desistance does not appear to exist,7,17 desistance alludes to the idea that GD or a TGE identity in pre-pubertal children will either “persist” through puberty or will “desist,” and the child will no longer have GD/a TGE identity after puberty. Articles from the 1960s to 1980s are often cited as the foundation for research on “desistance.”18–21 One of the most significant studies is from a book published by Richard Green in 1987 entitled “The ‘Sissy Boy Syndrome’ and the Development of Homosexuality.”22
• Despite being the foundation for desistance research, these early articles and books never mention desistance, rather focusing on the “gender deviant” behavior of femininity in people designated male at birth, and how this behavior is more often a predictor of homosexuality rather than “transsexualism.”18–21 No one designated female at birth was included in the studies conducted at this time, and all of these studies employed techniques to actively decrease the gender-deviant behavior, leading to psychological trauma for many of the participants.
• Desistance as a word has its origins in criminal research,28 and Zucker explains that he was the first person to use desistance in relation to the TGE pre-pubertal youth population in 2003 after seeing it being used for oppositional defiant disorder (ODD).
• From all of these collections of studies emerged the commonly used statistic stating that ∼80% of TGE youth will desist after puberty, a statistic that has been critiqued by other works based on poor methodologic quality, the evolving understanding of gender and probable misclassification of nonbinary individuals, and the practice of attempting to dissuade youth from identifying as transgender in some of these studies

Good rule of thumb: if you find yourself mentioning FRINGE and Kenneth Zucker in the same sentence, and your argument is criticisms of him and not his own positions are FRINGE, you should really reconsider your argument... Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:17, 13 May 2024 (UTC)

Regardless of what you think about Zucker, he doesn’t own desistance, and the concept isn’t based on him or his stats. It’s the topic of many papers by a range of researchers, and one that is taken seriously by MEDRS sources (e.g. by Cass), not dismissed. Whether the rate is 10% or 80%, it’s a pathway out of GD. So there is a non-transition resolution to GD that manifestly isn’t conversion therapy, and so can you please stop calling everything-that-isn’t-transition conversion therapy? Barnards.tar.gz (talk) 21:59, 13 May 2024 (UTC)

And as the MEDRS above note, the concept is not actually well defined or supported, and was indeed based on his stats. The claim "most kids who identify as trans change their minds" is pure WP:FRINGE.

The fact Cass quoted Zucker so extensively has in fact been one of the criticisms[19] so can you please stop calling everything-that-isn’t-transition conversion therapy? - I'mma call a spade a spade, Zucker practiced conversion therapy. The "most kids desist" idea was based on studies of youth put through conversion therapy. You cannot dance around that fact. Please don't call conversion therapy everything-that-isn't-transition because WP:CIR and Kenneth Zucker's article is right there as is the paragraph on his work in gender identity change efforts.

Whether the rate is 10% or 80% it's not 80%, and those 2 numbers are very different, , it’s a pathway out of GD. So there is a non-transition resolution to GD that manifestly isn’t conversion therapy, - and you keep ignoring my question, what is the treatment for GD? I am saying "for about 100 years, when a person wants to transition, nothing we do or say can stop them, so the treatment is letting them transition". You are saying "some people, who haven't transitioned, but plan to, decide not to, so when somebody wants to transition the treatment is __________"? (that blank is the question I keep asking you) You repeating "some people change their mind about transition" is irrelevant to the question: "what is the recognized medical treatment for wanting to transition"? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:39, 13 May 2024 (UTC)

You are slipping the terminology again. "Wanting to transition" is not a medical condition. You might think it sounds kinda like the same thing as gender dysphoria, and there is certainly overlap, but as you can see from the DSM-V[20], it's possible to have a GD diagnosis without wanting to transition. I mention this not to refute your central point, but to illustrate that playing fast and loose with the terminology is risky, and this is a topic where terminology is so important. If you substitute "gender dysphoria" with "being trans and wanting to transition", you've already implicitly begged the question.

I will ignore the CIR aspersion on the assumption that you thought I was trying to make any statement about what Zucker is or isn't, or what the desistance rate is or isn't. What I actually said was that desistance is a concept that has been studied independently of Zucker, so criticism of Zucker doesn't invalidate the concept. When Cass cites Zucker, she immediately then notes criticisms of his study, and then cites other independent studies, not as evidence for a recommended treatment, but to show that desistance is a non-trivial phenomenon worthy of consideration. You might think the desistance studies are poor quality, just like the transition studies, but that's not an argument for ignoring it, just like the poor quality of transition studies isn't an argument for ignoring that transition might benefit some people.

Now to your central point: first, I assume we are talking about youth GD, since we're on the Puberty Blocker page. There is no well-evidenced treatment for gender dysphoria, as we have seen from Cass. It might be that transition works for some people, it might be that some kind of therapy works for some people, it might be that doing nothing at all works for some people. We don't know. The evidence isn't good enough, and the guidelines aren't good enough. More research is needed, and options should be kept open, not shut down with tendentious accusations of conversion therapy for things that plainly aren't. It's very unhelpful for you to stridently present unsettled science as objective fact. Barnards.tar.gz (talk) 09:55, 14 May 2024 (UTC)

But you're ignoring the sociological context of "who gets a GD diagnosis and why" and "why was the diagnosis created" and "to whom is the diagnosis meant to refer"?

it's possible to have a GD diagnosis without wanting to transition. but it's impossible to transition without a GD diagnosis and the GD diagnosis exists to let people transition billably.

Here's what the APA says about gender dysphoria[21]:

• In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria.
• DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria.
• For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized.
• Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions typical of the other gender. The DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition.
• Persons experiencing gender dysphoria need a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas
• When it comes to access to care, many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care

Here's what the world health organization says about gender incongruence[22]:

• ICD-11 has redefined gender identity-related health, replacing outdated diagnostic categories like ICD-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood” respectively. Gender incongruence has been moved out of the “Mental and behavioural disorders” chapter and into the new “Conditions related to sexual health” chapter. This reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma. Inclusion of gender incongruence in the ICD-11 should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services.
• Gender incongruence of adolescence or adulthood : Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

IE - the people who defined GD and GI were explicitly clear, repeatedly, the diagnosis was a workaround to replace "being trans" as the diagnosis - to continue giving care to trans people without diagnosing them with "gender identity disorder" OR "transsexualism". It is not me (or, just me) saying "GD is non-pathologizing medical speak for being trans" - it is the APA and the WHO. And they are in agreement, for those who want to medically transition, the treatment is to help them do so. Not to try convince them they shouldn't. Not to make them wait it out. None of that. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 15:42, 14 May 2024 (UTC)

They do not literally say that. You are executing a masterpiece of paraphrase and synthesis, and the abstraction is leaking. Barnards.tar.gz (talk) 16:40, 14 May 2024 (UTC)

You are executing a masterpiece of ignoring what the sources are saying - ie, this diagnosis exists to let people bill for transition in a non-pathologizing way instead of diagnosing them with "transsexualism" or etc. Do you think people are being given a diagnosis of GD for something other than saying "I'm trans and want to transition?" Or, is it pure coincidence that the people being diagnosed with GD are just those saying "I'm trans and want to transition?" Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:08, 15 May 2024 (UTC)

It appears to at least be theoretically possible to get a GD diagnosis with only the criteria "A strong desire to be treated as the other gender" and "A strong conviction that one has the typical feelings and reactions of the other gender", so it's at least possible to be given a diagnosis of GD for something other than saying "I'm trans and want to transition".[23]

I don't know whether that happens in practice, but it's theoretically possible.

Note that up here you're arguing that GD == wants to transition, and that down below, you're arguing that when the Endocrine Society says only a minority of GD children become GD adolescents, that doesn't mean that only a minority of GD children will want to transition when they're older. These statements do not seem consistent to me. WhatamIdoing (talk) 19:46, 15 May 2024 (UTC)

If the sources actually said that, then you wouldn't need to use ie. It's time to drop the stick. Barnards.tar.gz (talk) 21:19, 15 May 2024 (UTC)

Zucker and Bradley put desistance at 88% in a followup study in 2021, but other clinicians have put desistance at 70-80% so even if Zucker's numbers are high, they are miles away from the "1%" desistance numbers often touted. Zucker's cohort is boys seen between 1989 and 2002, the majority are now gay or bisexual men, and this study achieved a 96% participation rate.

Whatever the individual reasons for these outcomes, simply waving research like this away as "conversion therapy" is to say that you would consider those 88% of mostly gay or bisexual men a failure, and they should have transitioned, but have been "converted" away from being the trans women they should have been. Really? Are you 100% sure about that? Can that claim be backed up with MEDRS?

The demographics presenting have changed drastically since this cohort, in terms of age, sex, numbers, and standard of intervention.

It used to be tiny numbers of same/both-sex attracted boys, presenting pre-adolescence, and even conservatively 70% grew out of it. Virtually the entire dutch protocol was based on same-sex attracted boys (only one was heterosexual in the initial cohort IIRC).

Now this has been applied to orders of magnitude more same/both-sex attracted girls, presenting in adolescence, with a lower diagnostic threshold, and if they are given puberty blockers less than 1% grow out of it.

Please stop dismissing difference of medical opinion as WP:FRINGE. The binary framing of "affirmation model" vs "conversion therapy" is a false and unhelpful one. There are huge open questions here, a paucity of high quality research, and this article needs to stick to what MEDRS actually say. Void if removed (talk) 10:35, 14 May 2024 (UTC)

And those studies are discussed above.

Whatever the individual reasons for these outcomes, simply waving research like this away as "conversion therapy" is to say that you would consider those 88% of mostly gay or bisexual men a failure, and they should have transitioned, but have been "converted" away from being the trans women they should have been. Really? Are you 100% sure about that? Can that claim be backed up with MEDRS? - a nonsensical claim: Zucker did not see "kids who identified as trans and wanted to transition" - he saw "kids who were in any way gender noncomforming".

• 1) Claiming the majority of kids who say "I'm trans and want to transition" change their mind is stupid when your evidence is "I asked people who didn't identify as trans when they entered my clinic if they identified as trans as trans when they left and their answer continued to be no". and they should have transitioned, but have been "converted" away from being the trans women they should have been. Watch your logic in action: "I asked everyone who walked into a building if they were gay - most said no - when they exited they continued to say no - this is proof the majority of gay men will go back to being straight - if you disagree or point out the flaws in my study, you're saying those straight people should have been converted to be gay"
• 2) Conversion therapy is the pseudoscientific practice of attempting to change an individual's sexual orientation, gender identity, or gender expression to align with heterosexual and cisgender norms - Zucker attemped to clamp down on gender variant expression as pathological. For the record, when the paper I quoted said all of these studies employed techniques to actively decrease the gender-deviant behavior, leading to psychological trauma for many of the participants. - you can read Zucker's article - that was because he thought the gay kids should be gender conforming. He thought kids who explicitly identified as trans should be discouraged. He definitely put the trans kids through conversion therapy, but he also did it to the gay kids. Unless, it's not conversion therapy to tell effeminate gays they're not masculine enough and having their parents try and correct that? FFS read Kenneth Zucker and gender identity change efforts.
• 3) The demographics presenting have changed drastically since this cohort, in terms of age, sex, numbers, and standard of intervention. - the cognitive dissonance here is actually shocking. The old demographic was "anybody gender noncomforming", the new one is "people who explicitly want to transition" - you are simultaneously saying "these are so different we can't compare them" and "the majority of people who want to transition grow out of it, look at the study of gender noncomforming youth"
• 4) Can you manage, or try, to not misgender and infantilize trans kids in your comments? Virtually the entire dutch protocol was based on same-sex attracted boys (only one was heterosexual in the initial cohort IIRC) - straight transgender girls. Now this has been applied to orders of magnitude more same/both-sex attracted girls, presenting in adolescence, with a lower diagnostic threshold, and if they are given puberty blockers less than 1% grow out of it. - straight/bisexual transgender boys. Not "girls who don't grow out of it".
• 5) I'd like to interact with you on one article where I didn't have to deal with your promotion of fringe nonsense and conversion therapy as a "difference of opinion".

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 14:51, 14 May 2024 (UTC)

I disagree quite strongly with your continual overuse of accusations of WP:FRINGE but in particular I would like you to not accuse me of promoting conversion therapy please. Void if removed (talk) 16:01, 14 May 2024 (UTC)

Let's move this conversation over here please, it's quite hard to read out by the right margin. Loki (talk) 17:14, 14 May 2024 (UTC)

It would help if you read what I wrote, and you quoted, rather than leap into a lecture on word origins. I never said that term itself was an activist term or inherently problematic. I said dividing the world into two blunt groupings is not helpful and is an activist tactic: one sees it in every form of activism and politics. It is an indicator the writer wants simply to score points rather than understand or explain nuance, and to push people and works into good and bad boxes.

I'm not here to debate the pathologizing of being trans. Do you any sources to back up your claim that children wishing physical transition have not since "decades ago" been referred to a team of clinical psychologists. The Dutch Protocol comes from: Annelou L. C. de Vries, "a child and adolescent psychiatrist working at the Amsterdam UMC/ Levvel Amsterdam Academic Center of Child and Adolescent psychiatry" and Peggy T Cohen-Kettenis is "is Professor of gender development and psychopathology at the Department of Child and Adolescent Psychiatry, University Medical Center Utrecht." and "a registered clinical psychologist and psychotherapist". In the UK, GIDS was part of a mental health trust and its director, Polly Carmichael, a consultant clinical psychologist. This is basic stuff, YFNS. -- Colin°^Talk 16:33, 12 May 2024 (UTC)

I semi-divided it into 2 blunt groupings, I was also being a fair bit more nuanced than you're giving me credit for, my thesis was PBs developed as part of a dialectic between a trend towards pathologization and a trend away from it and cannot be classified fully into either approach because both poles both approve/disapprove of them for different reasons. And as I've explained to you a few times, I think PBs are overall a stupid treatment - and insofar as I'm on a "side" I'm on the depathologizing one, which is currently the main champion of blockers, so your accusations of binary thinking fall flat when I'm calling a plague on both their houses.

You framed the assumption being transgender and transitioning are things to be avoided if possible as a fear that psychologist might do a bit of their actual job. That's categorically wrong, a psychologist doing their actual job treating trans kids should absolutely not assume transition should be avoided and a cis identity is preferable to a trans one. That assumption is the key underlying idea behind the pathologizing approach.

I did however make a mistake, my apologies, requiring psychotherapy to transition was somewhat dropped decades ago for adults in the WPATH SOC 5 (1998). It did however, keep the requirement of psychotherapy for youth and recommend against social transition until 18 (with at least 6 months of a shrink before social transition in case they want to do so earlier) [24]

Instead of Mandating psychotherapy as a requirement to transition ended decades ago, perhaps more clear and truthful would have been assuming that transition should be avoided if possible and mandating that trans people wanting to transition should be subject to psychotherapy aiming to figure out how trans they are or if they're just crazy ended about a decade and a half ago. Noting your dutch protocol example, they low-key assumed being trans should be avoided, which is why they gave the kids PBs instead of HRT. However, they did not encourage the kids not to be trans and did not mandate conversion therapy and etc, they just assumed some were wrong and thus PBs gave them time to figure it out without forcing them through an incongruent puberty in the meantime. A little pathologizing, mostly not. For the context of its time, incredibly depathologizing. A better example of high-key assuming being trans is pathological is Kenneth Zucker, whose treatment for trans kids was explicitly based on trying to steer them away from 1) transition and 2) transgender identity at all - even he wasn't 100% pathologizing (more like 95%) as he supported transition if conversion therapy during childhood didn't work.

Anyways, I'm not sure what we're even discussing with relation to the article. Getting back on track, it is my belief that we should better cover 1) the reasons given for why PBs are given to trans kids (primarily the suggestion it buys time for them to figure out their gender) 2) the contradictory fact the requirement for being prescribed them is being explicit you're trans and want to transition in the first place, and 3) the historical context for why they prescribed. Wrt the latter: for an article on a treatment for trans kids we should probably mention what treatment it replaced, which was at best going through an incongruent puberty until at least 16 years old if you were lucky and at worst just straight up getting conversion therapy. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:24, 12 May 2024 (UTC)

the reasons given for why PBs are given to trans kids

I cited MEDRS above, giving multiple reasons, we should stick to those. Void if removed (talk) 11:05, 13 May 2024 (UTC)

You cited a MEDRS, which doesn't contradict what I said at all.

• Rationales for puberty suppression in the Dutch treatment protocol, which has informed practice internationally, were to alleviate worsening gender dysphoria, allow time for gender exploration, and pause development of secondary sex characteristics to make passing in the desired gender role easier.
• Practice guidelines propose other indications for puberty suppression, including allowing time and/or capacity for decision-making about masculinising or feminising hormone interventions, and improving quality of life.
• I said the reasons given for why PBs are given to trans kids (primarily the suggestion it buys time for them to figure out their gender), which the original and newer reasons cited both include. I'm somewhat surprised they split them as separate though, the "time for gender exploration" in the original was pretty clearly it was because they didn't think the kids could commit to HRT/SRS at that age and they wanted them to be older when they started HRT in case they changed their mind - it's different language for the same premise.

I think the lead is overly politicized at the moment and should better cover

1. the reasons why they are given (per the above, we're not actually disagreeing about anything)
2. in what cases they are perscribed (per that same MEDRS National and international guidelines have changed over time and outline that medications to suppress puberty can be considered for adolescents experiencing gender dysphoria/incongruence., but through other MEDRS like those I cited to WID in this thread we can more clearly say that means kids who explicitly identity as trans and desire/are seriously considering medical transition). Relatedly, I think we should better summarize the dutch protocol and affirming shift.
3. what treatment option they replaced (ie, letting even the youth that the clinicians, shrinks, parents, and kids themselves involved were 100% sure were trans and would benefit from transition go through an incongruent puberty until the age of majority, and those who went through that had more difficulty passing and more stress)

Thoughts on updating the lead to better cover those 3 points? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:59, 13 May 2024 (UTC)

Well... I looked at the first paragraph of the lead, and I'm thinking that WP:TNT might be the best approach. For example, it says "used to postpone puberty in children", but it's mostly used in teenagers (and also young adults).

But for your #1, I think that the reasons (plural) are sort of sub-reasons. The "one reason" is: these young people want medical transition. The "multiple sub-reasons" are that we're not sure if a teenager not meeting the Dutch protocol actually knows what they're talking about, etc. WhatamIdoing (talk) 19:54, 13 May 2024 (UTC)

I'm not sure if we need TNT, just to draft a new lead.

Wrt your point on the "one reason", I don't think you can split it up like that, I think it's more accurately: these young people want medical transition and we don't believe they're old enough to consent to that but letting them go through an incongruent puberty is not a neutral option. PBs don't make sense unless the second part is included. we're not sure if a teenager not meeting the Dutch protocol actually knows what they're talking about - doesn't track because the Dutch Protocol had the same root issue: those meeting all the stringent requirements were given blockers instead of HRT until 16 years old in case they changed their minds anyways.

This is why I think we need to better frame it in terms of the previous / alternative treatments for transgender adolescents - the reasons for perscribing PBs need the context of what they replaced.

1. no medical care / psychotherapy only (what preceded PBs): kids who wanted to transition kept identifying as trans and transitioned when they reached the age of majority, but the delay caused irreversible pubertal changes that caused them lasting distress and difficulty passing
2. HRT (what they chose PB over): had been known to work for trans adults for decades, but they worried minors couldn't consent to that and might change their mind so didn't perscribe them
3. PB's therefore addressed the issues with both treatments by being the middle ground between "let them transition now" and "let them transition as an adult after incongruent puberty", settling on "let them transition as late teens if they still want to without having to go through incongruent puberty".

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:49, 13 May 2024 (UTC)

I keep getting reminded of a statement Cass made in the interim review, that BOTH SIDES cite WEAK or NON-EXISTENT science and made BOLD CONFIDENT CLAIMS. We end up with arguments like above where old poor studies on AMAB kids are fought about when that isn't even the referral cohort any longer.

The interview with Cass in the NYT sheds light on how the US is being forced into a not-giving-an-inch position as a result of politicians writing the clinical rules in over two dozen states. There's just too much in the above discussion which seems to be personal opinions, which are at one end of the scale, and don't acknowledge the existence of either alternative opinions, or even actual practice on the ground.

Further up a MotherJones article was linked as though evidence that Cass was seriously criticised by anyone we might take seriously. The text in that article says "More than once she cites notable exploratory therapists like Ken Zucker." As Void notes above, Cass immediately goes on to criticise that research. More importantly, you can check for yourself. Just open the Cass Review yourself and search for Zucker. He only appears in the "History of gender services for children and young people" where a study from prehistoric 1985 is mentioned and then immediately criticised and later in a summary of guidelines on social transition, where he is mentioned as being party of "early papers" and then also immediately criticised. This article also bangs on about RCTs and repeats the misinformation myth that seems now to be going around that although the York Reviews carefully examined the majority of research, none of which was RCT, Cass herself set a higher bar, with the confusing line "Some experts suspect that may be because she compared the research to RCTs despite their inappropriateness." Some unnamed experts eh? With their "suspicions". Or maybe the author's twitter echo chamber? I mean, Cass spends a lot of time citing and commenting on low quality research, with a critical eye, so we'd expect them to cite the odd discredited researcher if they played a role in the history of trans guidelines. It is a bit like, if Cass had concluded differently, a Telegraph writer had complained that Cass kept mentioning "the discredited WPATH". There's a body of research, and some of it, in a review like this, needs mentioned, even if to then be critical of it. We really don't need BS articles like that one informing our minds.

I think some of the "history" in the Cass Review may be useful to describe how thinking in this area has come about and whether in 2024 with the population cohort we are seeing at gender clinics, it is evidence based. We need to be careful to separate "this is why people, in the past, who mostly saw one or two AMAB kids a week, thought these might be useful" to whether there is a clinical consensus and evidence that this is the case in 2024. -- Colin°^Talk 16:17, 14 May 2024 (UTC)

Minority who desire medical transition?

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

I've changed that back and given a better citation too - I think that the different rationales for blockers described in MEDRS obviate giving such a straightforward wikivoice statement about desire for medical transition as a basis. Void if removed (talk) 09:29, 15 May 2024 (UTC)

It should be cited to the source I was actually relying on, which is doi:10.1210/jc.2017-01658 (the Endocrine Society's guideline), which says Combining all outcome studies to date, the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence. WhatamIdoing (talk) 17:57, 15 May 2024 (UTC)

They did not say, as you did that only only a minority of young transgender people ... desire medical transition[25]

They were saying "based on the data we have (in 2017), childhood (pre-pubertal) GD/gender incongruence doesn't persist into adolescence most of the time". They did not say "most kids who identify as trans don't want to transition". They offered a lot more caveating than that short quote allows for:

With current knowledge, we cannot predict the psychosexual outcome for any specific child. Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). Combining all outcome studies to date, the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence (20, 40). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.

The review Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review was published in 2022 and found

the focus of the more recent literature in the late 2000s is interested in rates of desistance and determining childhood factors before puberty, which can be used to predict desistance after puberty commences,30–33 often seen as a way to help clinicians decide on whether GAC should be provided. From all of these collections of studies emerged the commonly used statistic stating that ∼80% of TGE youth will desist after puberty, a statistic that has been critiqued by other works based on poor methodologic quality, the evolving understanding of gender and probable misclassification of nonbinary individuals, and the practice of attempting to dissuade youth from identifying as transgender in some of these studies.4,16,34–36

Second, some definitions of desistance focus on GD, while others focus on gender identity. An almost equal number of articles referred to desistance as the disappearance of GD as did articles that referred to desistance as the change of a transgender identity to a cisgender identity. Disappearance of GD and a change in gender identity are two concepts that, while occasionally connected, remain distinct. GD is associated with significant distress at the differences between gender and body, whereas a TGE gender identity does not require that distress. Therefore, a TGE child could still identify as TGE even if they do not experience GD. Despite having stated difference in these definitions, all the articles conflated these two ideas, implying that the disappearance of GD also meant that the TGE child identified as cisgender after puberty.

Based on this review of the literature, scarce hypothesis-driven research dedicated to desistance and/or persistence exists, with the majority of publications falling into an editorial category. This is important to note as it highlights the controversy and emotions that encircle TGE children.67 It is puzzling that 22 editorials can argue for or against the provision of GAC based on only 5 quantitative studies, all of which had relatively small sample sizes and substantial risk of bias. While some would argue that there are many more quantitative studies, in reference to the early work done in 1960s–1980s, these works were not explicitly exploring the phenomenon known as “desistance,” nor were they scientifically sound as they occurred in environments that viewed minority sexual orientations and gender identities as pathological and actively attempted to “cure” and/or prevent them.

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:00, 15 May 2024 (UTC)

Let's say we have a population of 10 prepubertal children who have GD/GI. GD/GI is more specific than having some sort of trans identity.

According to the Endocrine Society, GD/GI (not merely "being trans") "appears to persist in adolescence" for "a minority". So in adolescence, that means less than half of the original 10 have GD/GI. Let's say it's 4, because that's the biggest number we can have without contradicting the Endocrine Society's statement. Therefore, we previously had 10 children with GD/GI; now we have 4 adolescents with GD/GI and 6 adolescents that do not have GD/GI (any longer).

According to your comments above, GD/GI is defined in such a way that if you want to transition, you definitely have GD/GI. Therefore, the maximum number of adolescents in my story who (still) want to transition is 4, and it's probable that the number is lower than that (because, according to your comments above, it's possible to have GD/GI and not want to transition).

I do not see any mathematically sound way to accept the Endocrine Society's statement that only a minority of children who have prepubertal GD/GI continue to have GD/GI in adolescence, the DSM definition that anyone who wants to medically transition has GD, and then believe a majority of those children go on to seek medical transition. That would require believing that people want to medically transition when they do not have GD, which is defined as including every person who wants to transition.

Karrington's view has much to recommend it, but the paper is basically a complaint that good research doesn't exist. It doesn't say that, or produce any evidence to support a belief that, a majority of prepubertal GD/GI children go on to seek medical transition. WhatamIdoing (talk) 19:26, 15 May 2024 (UTC)

According to [my] comments above, GD/GI is defined in such a way that if you want to transition, you definitely have GD/GI [these days]. As the Endocrine society's comment above states, the DSM-IV text revision criteria for a diagnosis were rather broad. For a start, they did not require you to 1) want to medically transition or 2) actually identify as a gender not assigned at birth. the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood links to studies which say "yeah the kids who insisted they were trans or wanted to transition (as opposed to just gender noncomforming kids) were the ones saying they wanted to transition later". In addition, "gender incongruence" was introduced in the ICD 11 2 years after this was published - they are not referring to GI as a formal diagnosis.

I do not see any mathematically sound way to accept... that is because you are not accounting for time: the diagnostic criteria and therefore the patient cohort has shifted. It is no longer feminine gay boys and tomboyish lesbians being referred by their parents worried their kids might be trans and some trans kids. It is kids who are explicit they are trans and want to transition. It doesn't say that, or produce any evidence to support a belief that, a majority of prepubertal GD/GI children go on to seek medical transition what it does it point out those studies are not evidence that either 1) the majority of children who identify as trans pre-puberty change their mind or 2) the majority of pre-pubertal children who want to transition decide not to transition - because the studies were never tracking "youth who explicitly want to medically transition" or even "youth who identify as transgender".

TLDR: The Endocrine society explicitly caveats that they are guessing based on old data from old diagnostic criteria and new studies are needed to see if the numbers hold for their current definition - they are not saying that these numbers are definitively accurate for the current definition of GD and they are not saying "only a minority of transgender youth want to transition". Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:28, 15 May 2024 (UTC)

It sounds like you solve the problem by simply rejecting the Endocrine Society's statement that only "the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence". WhatamIdoing (talk) 03:40, 16 May 2024 (UTC)

"GD/gender incongruence...of prepubertal children" is not the same thing as "transgender youth". GD/GI persisting (involuntary) is not the same thing as choosing medical transition (voluntary). Stating that only a minority of transgender youth desire medical transition implies the other part of that same set - a 'majority of transgender youth' - don't desire medical transition, creating out of thin air a large population of youth who identify as transgender but desire no medical transition. Crossroads ^-talk- 17:48, 16 May 2024 (UTC)

That's just saying that a majority of children who present clinically with gender dysphoria grow out of it. It isn't quite the same thing as a minority desiring medical transition. Void if removed (talk) 20:37, 15 May 2024 (UTC)

Do children who "grow out" of GD still want to medically transition? Does anyone without GD want to medically transition?

If the answer to both of those questions is no, then "majority out grows" == "minority desires medical transition". WhatamIdoing (talk) 03:37, 16 May 2024 (UTC)

No that's not quite true, a few things are being conflated here, and it doesn't help that there are different rationales for giving blockers which is why this needs to be as neutral and source-based as possible.

Some clinicians are giving blockers to adolescents because they are treating gender dysphoria as a condition. The reasons here include directly alleviating the distress at the development of secondary sex characteristics, to pausing them to give "time to think" to see if they want to transition when they are older.

Some clinicians however are giving blockers to facilitate a medical transition, ie the gender dysphoria is not being treated, the dysphoria is seen as a symptom of not being affirmed. This more closely tracks the Dutch Protocol where it was an early medical intervention on mostly same-sex attracted males to "pass" better as the opposite sex in adulthood, but also includes delaying development until the child reaches legal age to consent to further treatment.

And this is where it gets complicated because time to think isn't actually panning out in retrospect, because >99% persist into adulthood, and blockers in reality are the initial phase of medical transition.

But because of the "time to think" rationale, you can't say this is about "wanting" to medically transition in all cases. In some it has been clinically prescribed to see if the child will want to transition, on the (incorrect) understanding that blockers aren't medical transition, but just a reversible pause.

You can't just equate GD and "desire to transition" like that, these are more complex and disputed clinical areas.

All we can say is: historically, children presenting with gender dysphoria mostly resolve this in adolescence and grow up to be LGB adults - and clinicians have never been able to predict which would persist and which wouldn't. Meanwhile, virtually all children presenting with gender dysphoria who are given blockers do not resolve the dysphoria in adolescence, and do go on to cross-sex hormones. Void if removed (talk) 08:39, 16 May 2024 (UTC)

The problem with making historical claims about gender dysphoria is that the clinical diagnosis GD only exists since 2013 (i.e., the DSM-5 revision) and emphasises different criteria than previous diagnoses (i.e., gender identity disorder) [26] Note especially that criterion A1, the "repeatedly stated desire to be, or insistence that he or she is, the other sex", wasn't necessary in the DSM-IV, but is necessary in the DSM-5 (see source 1 again, p.14-15). In other words, the DSM-IV(-TR) allowed for someone to be diagnosed with gender identity disorder even without identifying as the other gender (for all the criteria in DSM-IV-TR, see p. 537-538 [27]; note how category B can be met, again, not necessarily if someone experiences aversion of one's primary/secondary sexual characteristics, but if one has 'an aversion toward rough-and-tumble play', rejects 'male stereotypical toys, games, and activities', or has a 'marked aversion toward normative feminine clothing'; lastly, also note that the sexual orientation specifier was removed in the DSM-5, because, [1, p.15]: "The subtyping on the basis of sexual orientation has been removed because the distinction is not considered clinically useful.").

Besides, as same-sex attracted individual's behaviour can be (but doesn't have to be) interpreted as gender-non-comforming,it's easy to see how queer people who weren't trans could actually be diagnosed with GID and ended up not trans.

So, all we can say historically is that diagnostic criteria changed multiple times, making it impossible to compare cohorts with different diagnoses in any meaningful way. All we can say is that the chances of GD persisting is greater in the population diagnosed with the DSM-5 than the chances of GID persisting in the population diagnosed with the DSM-IV-(TR), because the current criteria are "more restrictive and conservative" [1, p. 14].

PS: The DSM-5-TR made some revisions to the DSM-5 diagnosis, but these were only linguistic in nature: "Reflecting the evolving terminology in the area of gender dyspho-ria, “desired gender” is replaced with “experienced gender”; “natal male/natal female” with “individual assigned male at birth” or “in-dividual assigned female at birth”; and “cross-sex treatment regi-men” with “gender-affirming treatment regimen”." ([28], p. 219). Cixous (talk) 12:20, 16 May 2024 (UTC)

the "repeatedly stated desire to be, or insistence that he or she is, the other sex", wasn't necessary in the DSM-IV, but is necessary in the DSM-5

Only in pre-adolescent children - and since puberty blockers are an adolescent intervention, the adolescent criteria apply, which has no such restriction.

And the actual wording of the criteria in the DSM-5-TR is "A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)." Nothing about sex there at all.

So for puberty blockers generally and especially the new mostly-female cohort who are presenting in larger numbers adolescence, none of what you're suggesting applies, and even if it did the use of gender in place of sex makes it especially confusing. Void if removed (talk) 12:43, 16 May 2024 (UTC)

I was really only replying to your statement that we can make any reliable historical claims about the persistence of GD as the diagnosis only stems from 2013. So, coming back to your points:

1. Note how that is the only criterion focusing on one's experienced gender (to use the current terminology); the latter criteria in the DSM-IV only reflect gender performance (though A3 can be interpreted as both), whereas the current guidelines focus solely on experienced gender (though the second to last criterion can be interpreted as closer to gender performance [29]). In other words, whereas the DSM-IV states that the only criterion for experienced gender is not necessary, they are very much necessary for the DSM-5-TR.
2. I know the wording has changed. I cited the older DSM-IV-TR to illustrate the point. The document I provided actually states that the criterion was retained, made necessary (for children, you're right about that), but changed in terminology to better reflect our current understanding of sex and gender.

Again, I didn't mean to imply in any way that the DSM-IV(-TR) criteria should apply again, nor that they have any clinical significance for the current population, but that the statement "All we can say is: historically, children presenting with gender dysphoria mostly resolve this in adolescence and grow up to be LGB adults" is not really accurate considering how different the diagnostic criteria are. I apologise if I digressed by pointing that out, but I felt that it was necessary to do so.

To return to the main topic: gender dypshoria (DSM) or gender incongruence (ICD-11) is necessary for medical transition, the difference being that the former is accompanied by "clinically significant distress", whereas the latter isn't.

Besides, the original rationale for the Dutch protocol was to give individuals more time to think about their wish for 'gender reassignment' (as it was called at the time). The benefits of better passabilitiy and less distress were mentioned as well, but these could have been easily obtained through early intervention. In other words, the 'time to think' suggestion was actually put forward by the Dutch team in the first place, because, quoth Delemarre-van de Waal & Cohen-Kettenis (2006, p. S132): "This treatment is a very helpful diagnostic aid, as it allows the psychologist and the patient to discuss problems that possibly underlie the cross�gender identity or clarify potential gender confusion under less time pressure. It can be considered as ‘buying time’ to allow for an open exploration of the SR wish." So, it was proposed as a reversible treatment option (which was also shaped by the Dutch legal context at the time: e.g., de Vries & Cohen-Kettenis, 2012).

The idea whether or not the 'time to think' suggestion actually works, is unsurprisingly, not new either. In fact, it was mentioned in the original paper that introduced the concept. Quoth Cohen-Kettenis & van Goozen (1998, p. 248): "Although the phys�ical side effects [of puberty suppresion] are few (4), this option also has its risks. Adolescents may consider this step a guarantee of sex reassignment, and it could make them therefore less rather than more inclined to engage in introspection." The difficulty of determining whether or not puberty suppression determines a medical pathway isn't helped by the fact that the increase in referrals concurred with the introduction of the stricter DSM-5 criteria, making it more difficult to make out which of the two is responsible for the persistence of gender dysphoria. ES itself mentions there is a lack of knowledge about how often GD persists and how often it remits. The question is whether or not such a research gap can be meaningfully adressed at all without running in ethical issues, making this such a contested part of medicine.

PS/Off-topic: Getting back to all these sources, I think a history section should at the very least include the idea that puberty suppression would reduce 'false positives', as YNFS pointed out in a different section. Another question, namely whether or not this claim is unfounded, is not up to us here. Cixous (talk) 14:07, 16 May 2024 (UTC)

Void, I'm feeling like your response amounts to saying that the Endocrine Society is wrong.

Given suitable value for Y, this feels to me like a pretty basic logic statement of the sort that one might encounter in the first week of a university class on logic:

• A majority of X do Y.
• Therefore, a minority of X don't Y.

But when "X" is defined as "prepubertal children with GD/GI" and "doing Y" is "persist during adolescence", e.g.,:

• A minority of prepubertal GD/GI children persist during adolescence
• Therefore, a majority of prepubertal GD/GI children don't persist during adolescence

the logic is declared to not hold, apparently on the grounds that some editors think the Endocrine Society is wrong to say these prepubertal children had GD/GI.

We have AFAICT exactly zero evidence that 100%, or even ≥50%, of today's GD/GI five year olds are going to need puberty blockers. Sources welcome, but none appear to be forthcoming. I see a whole lot of rationalization here from Wikipedians about why "a minority...persist" somehow does not logically mean that "a majority doesn't persist", but I see no sources saying that.

So I want you to imagine that you are a parent with a five year old who has GD/GI. I emphasize the age so that we can stop talking about "adolescents" and "youth". I'm talking about a little child who probably doesn't even know how to read yet. According to what I read in the Endocrine Society's guideline, it is possible but unlikely (≤50%) that this child will – at a future date, say, ten years from now, when the adorable little child is arguing about driving privileges and social media rules – still have GD/GI.

The Endocrine Society admits to some uncertainty about which children and will not be drawn on exact numbers, but they clearly state that only "a minority" of the humans who have GD/GI when they are little children grow up to have GD/GI as teenagers.

Or, if you don't want to take this from the POV of a parent, consider if from the POV of the health system administrator. You know that you have 1,000 pre-pubertal children with GD/GI in your system. Your task is to estimate how many of the existing patients will need which services five years from now. Are you going to estimate that 100% of today's five year olds will qualify for puberty blockers and hormone treatments? Or are you going to follow the Endocrine Society's statement and estimate that less than half of them will need medical transition help (but that a few hundred of them might need LGB services)? WhatamIdoing (talk) 04:12, 19 May 2024 (UTC)

I personally don't dispute the claim that the majority didn't used to persist in adolescence. I argue that's true.

I just think there's a difference between:

• Early childhood gender dysphoria persisting beyond adolescence
• Desiring medical transition

It isn't that a minority "desire transition" - its that a majority (used to) grow out of it.

Desire to transition is a messy concept and one I don't think we should be introducing here, especially not as a basis for desistance. You also can't straightforwardly compare cohorts where blockers were not in use and say that a minority would now receive them, since there's significant age overlap between qualification and resolution.

If, say, you're giving blockers from Tanner 2, but GD resolution doesn't normally happen until Tanner 5 then what we have now is a cohort who would qualify for blockers during that window and will persist if given them but historic rates show the majority would have desisted a few years later if not given them.

And that's without accounting for what seem to be the majority of today's cases who aren't persisting from childhood at all, but are presenting in adolescence.

you have 1,000 pre-pubertal children with GD/GI in your system. Your task is to estimate how many of the existing patients will need which services five years from now. Are you going to estimate that 100% of today's five year olds will qualify for puberty blockers and hormone treatments?

If you were to go off historic desistance numbers, no. If you were to base this on Olson et al 2022, the answer would be yes. Because we now have a cohort who are socially transitioning from a very young age, without clinical oversight and with parents who think a GD diagnosis is unethical and unnecessary, and it very much seems the pathway from early social transition to blockers at Tanner 2 to hormones changes the picture from minority, to virtual certainty.

Some are trying to suggest this shift is because the DSM5 criteria for childhood is stricter than it used to be, so that the now near-100% rate is legitimately because the diagnostic criteria are better. I think that's untenable - the criteria aren't actually any more stringent and seemingly aren't even being applied anyway, rather it is more likely the shift to early affirmation and then blockers at Tanner 2 which is leading to near-universal persistence rates. Void if removed (talk) 09:12, 19 May 2024 (UTC)

recent removal of content

I removed the content on the recent emergency power ban of puberty blockers by the UK gov. The reason being that no medical organisation was reached out to so it shouldn't be in stances of medical organisations and that the legislation is more complicated than a strict ban (under 18s already on it through the NHS are excluded, other uses are allowed). As well as this the long term impact of this ban seems very suspect.

Main reason for making this was expanding the ideas given for removal and making an easy place for discussion about inclusion on the topic. LunaHasArrived (talk) 13:07, 1 June 2024 (UTC)

Ah yes, my mistake, edited "united kingdom" and missed the section header was about medical orgs. Void if removed (talk) 21:27, 1 June 2024 (UTC)

Sources

The 2020 review by Rew and the 2024 review by Baxendale are available at no charge to editors through Wikipedia:The Wikipedia Library.

There is also free access to these papers:

• Wenner, Danielle M.; George, B. R. (November 2021). "Not just a tragic compromise: The positive case for adolescent access to puberty‐blocking treatment". Bioethics. 35 (9): 925–931. doi:10.1111/bioe.12929. ISSN 0269-9702.
• Boskey, Elizabeth R. (2019-12-20). "Transgender Youth: Development of the Self in Adolescence Gender". In Hupp, Stephen; Jewell, Jeremy (eds.). The Encyclopedia of Child and Adolescent Development (1 ed.). Wiley. doi:10.1002/9781119171492.wecad481. ISBN 978-1-119-16189-9.
• Ludvigsson, Jonas F.; Adolfsson, Jan; Höistad, Malin; Rydelius, Per‐Anders; Kriström, Berit; Landén, Mikael (November 2023). "A systematic review of hormone treatment for children with gender dysphoria and recommendations for research". Acta Paediatrica. 112 (11): 2279–2292. doi:10.1111/apa.16791. ISSN 0803-5253. (open access)

which might interest some of the regular editors. These are all on the Wiley site. Try these steps:

1. Go to https://wikipedialibrary.wmflabs.org/ and login with your regular Wikipedia account.
2. Under "My Collections", almost at the end of the page, find the box for Wiley. Click on the blue "Access collection" button.
3. That will take you to the Wiley search page. Put the title of the article/chapter/book into the main search box.
4. Click on the matching result. Some of them display on the page, and some require you to download the PDF. (Downloading a whole textbook takes a long time. I've had better results with picking and choosing chapters.)

Please let me know if you found this helpful. WhatamIdoing (talk) 21:42, 1 June 2024 (UTC)

Puberty blocker article evaluation

Work by group 7! — Preceding unsigned comment added by L. Alvarez113 (talk • contribs) 22:01, 23 July 2024 (UTC)

Although the article discusses the use of puberty blockers in a practical sense, it lacks drug information and could be improved with this proposed editing plan:

• Discuss basic drug information including the mechanism of action, drug-drug interactions, safety and efficacy concerns, and an updated long-term effects section.
• Add infographic detailing gonadotropin-releasing hormone and anti-androgens (spironolactone) agonism and antagonism.
• Develop the health disparities section and discuss issues with affected marginalized groups.
• Add credible sources and information detailing the use of puberty blockers for the treatment of established medical conditions.
• Improve the worldwide view by taking credible information from various sources and organizations.

L. Alvarez113 (talk) 21:42, 23 July 2024 (UTC)

@L. Alvarez113: The drug information is presented at Gonadotropin-releasing hormone agonist. This article is about puberty blockers in general, not a specific drug. Nosferattus (talk) 03:43, 25 July 2024 (UTC)

The most useful thing you could add to this article is information about the use of puberty blockers to treat precocious puberty, as there is almost nothing in the article about that. Nosferattus (talk) 14:51, 25 July 2024 (UTC)

Please see discussion at Talk:Puberty_blocker/Archive_4#Overall_article_structure, which IIRC resulted in a proposal to minimise this content, and leave those to be covered at Gonadotropin-releasing hormone agonist and Precocious puberty Void if removed (talk) 14:58, 25 July 2024 (UTC)

Hmm, that discussion seems to show support for splitting the article into one article focused on gender-affirming care and one focused on precocious puberty, but the article was never actually split (perhaps because the discussion did not result in a clear consensus). Without the article being split, I don't think it makes sense to remove content about treating precocious puberty as that is one of the main uses of puberty blockers. Nosferattus (talk) 15:16, 25 July 2024 (UTC)

Copyright problem removed

Prior content in this article duplicated one or more previously published sources. The material was copied from: https://www.theguardian.com/society/2024/apr/11/ban-on-childrens-puberty-blockers-to-be-enforced-in-private-sector-in-england https://segm.org/German-resolution-restricts-youth-gender-transitions-2024. Copied or closely paraphrased material has been rewritten or removed and must not be restored, unless it is duly released under a compatible license. (For more information, please see "using copyrighted works from others" if you are not the copyright holder of this material, or "donating copyrighted materials" if you are.)

For legal reasons, we cannot accept copyrighted text or images borrowed from other web sites or published material; such additions will be deleted. Contributors may use copyrighted publications as a source of information, and, if allowed under fair use, may copy sentences and phrases, provided they are included in quotation marks and referenced properly. The material may also be rewritten, provided it does not infringe on the copyright of the original or plagiarize from that source. Therefore, such paraphrased portions must provide their source. Please see our guideline on non-free text for how to properly implement limited quotations of copyrighted text. Wikipedia takes copyright violations very seriously, and persistent violators will be blocked from editing. While we appreciate contributions, we must require all contributors to understand and comply with these policies. Thank you. ⸺RandomStaplers 05:37, 25 July 2024 (UTC)

Where’s the copyvio? The reports that are linked in the header box both say “violation unlikely”. Barnards.tar.gz (talk) 07:51, 25 July 2024 (UTC)

I'd ignore the % figure as that's for the page as a whole. If you check against the old revision, it looks like a few sentences have been lifted verbatim from The Guardian here.

Some of the matches are just titles like Care Quality Commission, but yes there's some copy + paste of article text going on there.

The SEGM text here is substantially a quote, and the quote is from here, but I guess its an english translation so they own the copyright on it?

@Randomstaplers I'm not familiar with how this works, rather than rolling back to May can we not just remove these sections? There's a couple of months of unrelated changes we're about to lose. Void if removed (talk) 10:44, 25 July 2024 (UTC)

I've now updated it to the last consensus version, but with the contentious sections removed. Void if removed (talk) 13:32, 25 July 2024 (UTC)

We went from having a minor copyright problem to a major copyright problem. Now we have dozens of edits worth of content, including entire sections, with no proper attribution. Nosferattus (talk) 13:44, 25 July 2024 (UTC)

This is why I asked for advice, but the revisions have all been deleted now.

Frankly, I don't want to lose 2 months of often quite painstakingly arrived at consensus, however it is attributed. Void if removed (talk) 14:01, 25 July 2024 (UTC)

@RandomStaplers: Can you restore the original history in order to fix the content attribution? Nosferattus (talk) 13:57, 25 July 2024 (UTC)

@Randomstaplers: Also, why does your signature not match your username? That's annoying. Nosferattus (talk) 13:59, 25 July 2024 (UTC)

• @Nosferattus AFAIK, the history is what's required for content attribution. That's why rolling back + edits on the page are no big issue, but copying between pages is not. See this page for details.⸺Random(s)taplers 18:42, 25 July 2024 (UTC)
• Basically, you can go ham with the page to get rid of a copyvio; MediaWiki should be able to track the changes, and the page history serves as CC-license attribution.⸺Random(s)taplers 18:44, 25 July 2024 (UTC)

(Also sorry for the signature - that was an old signature I made years ago)⸺Random(s)taplers 18:45, 25 July 2024 (UTC)

@Randomstaplers: Void if removed reinstated most of the original content, but without attribution. And there is no longer any way to access the original revisions to see who added what. For example, if I want to reuse the "Neurological effects" section, there is no way for me to figure out who to properly attribute it to. Isn't this a copyright violation just as much as copying content from The Guardian or another Wikipedia page? Nosferattus (talk) 01:12, 26 July 2024 (UTC)

@Nosferattus According to section 4, subsection C, and section 1, subsection f of the Creative Commons code, no. You just need the name. And since the name is in the page history... no violation here(!)⸺(Random)staplers 01:16, 26 July 2024 (UTC)

• @Nosferattus On the other hand, the GFDL wants the preservation of a "network location." I'm not a lawyer, but... so long as no one distributes this article under the old GFDL, everyone should be good.
• Dual licensing, AFAIK, does not bind you to the terms of a specific license. You can choose one, or the other, and go ham with it. (Picture this: you dual license CC-BY (almost public domain) and something else, the thing would effectively be CC-BY, despite the terms of something else)
• Since the original contributor licensed under GFDL+CC-BY-SA 3.0, you've effectively incorporated the content under CC-BY-SA 3.0. This does have the consequence that nobody can distribute under GFDL anymore, from what I can tell, but that's no big loss, since nobody uses that license anyway.
• But, if for some reason, you needed to distribute under GFDL, I guess you could ask an administrator to retrieve the edit for you...?⸺(Random)staplers 01:29, 26 July 2024 (UTC)

  • @Nosferattus CC-BY-SA-4.0... section 3-a-1-A-i: There's no requirement to preserve the metadata, just the identification of the creator. Their name, basically, plus the license, plus a URL to the extent "reasonably practicable" - I have to assume that's the history page, cause that's the obvious place for attribution, and an admin is withholding your access, to you and everyone else--that's beyond your control. Probably ticks the "reasonably practicable" box. In my non-lawyer opinion.⸺(Random)staplers 01:44, 26 July 2024 (UTC)

I'm sorry, but I'm not convinced that having secret attribution that is only accessible to admins is a good solution. I guess I'll start a discussion about this at the village pump so that it can be hashed out more comprehensively. Nosferattus (talk) 02:05, 26 July 2024 (UTC)

@Nosferattus Well, good luck. Next time, remember to include some sort of URL in the edit summary to avoid these issues in the future.⸺(Random)staplers 02:12, 26 July 2024 (UTC)

FYI: Wikipedia:Village pump (policy)#Copyvio revdel question. Nosferattus (talk) 02:32, 26 July 2024 (UTC)

Wiki Education assignment: Foundations II

This article was the subject of a Wiki Education Foundation-supported course assignment, between 1 June 2024 and 17 August 2024. Further details are available on the course page. Student editor(s): Mallai98, L. Alvarez113, DBarfield88, T. Banks UCSF Pharm.D. Candidate (article contribs). Peer reviewers: A. Shahbazi1, Cbtrinh, Dphan2, Ybramos, Htran2026.

— Assignment last updated by Health Economics and Policy (talk) 19:28, 26 July 2024 (UTC)