Talk:Puberty blocker/Archive 6

Archive 1

←

Archive 4

Archive 5

Archive 6

Peer reviews from Group #6

Question 1. Do the group’s edits substantially improve the article as described in the Wikipedia peer review “Guiding framework”?

The group did a great job discussing the role of puberty blockers in individuals with precocious puberty and expanding on medical consensus in other countries. The lead is well executed but does contain information on medical boards specific to America and Australia. I would recommend including information on international guidelines, since country specific guidelines are expanded later on. The sections are organized in a chronological order. As part of the “Guiding Framework” and the group’s goals, I agree with adding information on underrepresented populations. The content is also well written and easy to read. A. Shahbazi1 (talk) 03:24, 30 July 2024 (UTC)

The article is very comprehensive and provides a lot of details regarding the subject, not just medical information but also social implications around the subject. Although the article is heavily focused on the political environment in America of puberty blockers, the article also provides the guidelines around the world regarding the use of puberty blockers, which helps to provide a more holistic view. Cbtrinh (talk) 23:41, 29 July 2024 (UTC)

The group provided an in-depth explanation of puberty blockers and the numerous ways they can affect/ impact individuals. The article references guidelines from international medical organizations, which provides insight into the consensus and findings regarding puberty blockers. In addition, the article incorporates information from multiple credible sources around the world. This allows readers to gain a better understanding from different perspectives and see how different countries have approached the research. Dphan2 (talk) 04:32, 30 July 2024 (UTC)

I think the group discusses the role of puberty blockers in individuals with precocious puberty well and also improves upon the worldwide view by including organizations outside of the United States that supply the medications. The additional information for precocious puberty is useful for those experiencing it. The additional information about other companies that produce around the world improves accessibility for individuals looking to Wikipedia across the globe. They also added some information about mechanisms of action to help supplement neutral, scientific information. The group does a great job overall, adding in much-needed scientific information and additional sources. Htran2026 (talk) 05:30, 30 July 2024 (UTC)

The article provides a comprehensive overview of puberty blockers, their various uses, and the risks/benefits of their use. The addition of drug names and suppliers around the globe could greatly improve accessibility and education for people seeking more information of the various medications available. There is a heavy focus on the controversy over the use of puberty blockers in the United States, and although links are provided for organizations across the globe, a quick summary of arguments from both sides could be helpful. Ybramos (talk) 20:11, 30 July 2024 (UTC)

Question 2. Has the group achieved its overall goals for improvement?'

While the team has expanded on precocious puberty and medical consensus in other countries, I believe there is room to add additional information based off the goals they have listed. It appears that long term data is limited, but the group can add information on whether there are any ongoing trials to assess long term effects. In addition, it is hard to follow the political challenges section. I am unsure of which countries are being mentioned here aside from the U.S. The section could be divided into smaller categories like the medical organizations section. A. Shahbazi1 (talk) 03:24, 30 July 2024 (UTC)

The team has added a section about the different medication classes of puberty blockers and provided examples of these medications by name. I think a basic mechanism of action should be provided for each of the drug classes for clarity on how each drug class differs from each other. Otherwise, I think the group achieved most of their goals for improvement. Cbtrinh (talk) 23:49, 29 July 2024 (UTC)

The article is very informative and has met several of the goals listed above; however, there is room for improvement, as not all goals have been fully met. For example, it would be helpful if the article included infographics to help readers better understand the mechanism behind agonism and antagonism. In addition, I agree that more information regarding the different types of puberty blockers would be beneficial for readers to understand the difference between their mechanism of action and functions. Dphan2 (talk) 04:59, 30 July 2024 (UTC)

The group completed some of their proposed edits to the articles including adding drug names, indications for use, and safety and efficacy profiles of these medications. An area of improvement would be to include mechanism of action and adverse effects for each type of puberty blocker, and when one type of puberty blocker could be considered over another. One of the proposed edits was to add a Health Disparities section, which would have been a great addition to this article. Ybramos (talk) 20:11, 30 July 2024 (UTC)

The group achieved some of the overall goals for their project. They added in worldwide sources, including companies from outside the US. They also added in information about new antagonists and linked specific drug names. They also added in information about precocius puberty blockers, which was also helpful. They're missing more development on health disparities and mechanisms of actions. Overall, I think they achieved most of their goals. Htran2026 (talk) 22:25, 30 July 2024 (UTC)

Question 3A: Does the draft submission reflect a neutral point of view?

I believe the legal status and political challenges can be reworded to have a more neutral tone. For example, instead of saying "some opponents...", the phrase can be reworded to say "an argument can be made that..." Otherwise, I think the first half of the article does reflect a neutral point of view. Cbtrinh (talk) 23:55, 29 July 2024 (UTC)

The draft reflects a neutral point of view in the sense that it includes information from various sources globally. It is very transparent regarding the research/ lack of research conducted. Dphan2 (talk) 05:36, 30 July 2024 (UTC)

Question 3B: Are the claims included verifiable with cited secondary sources that are freely available?

Based on what the team added, most of the sources are secondary and freely available. In the precocious puberty section, citations 20, 21, and 22 back up the paraphrased information in the article. Source 20 was published in 2008 and is outdated; however, the source is only used to describe a mechanism. Sources 23 and 24 are a bit outdated and do describe treatments; I would confirm there is no additional updates from more current sources. Sources 24 and 26 appear to be primary sources as they are pilot studies. I would recommend finding a secondary source if available. A. Shahbazi1 (talk) 19:50, 29 July 2024 (UTC)

Question 3C: Are the edits formatted consistent with Wikipedia’s manual of style?

The article displays clear headings and a lead section that briefly states what the article will cover. However, some headings could be used and may be helpful in organizing information such as Contraindications, Adverse effects, Drug interactions, Mechanism of action, Manufacturing, Society and culture (which may include: Legal status, Economics, Brand names), and Research. Citations and references are appropriately added and consistent. Ybramos (talk) 20:48, 30 July 2024 (UTC)

Question 3D: Do the edits reflect language that supports diversity, equity, and inclusion?

Overall, the article is written in a way that does not seem to exclude any populations or groups of people. With that said, the use of the word "patient" does make it sound like people who seek to use puberty blockers are needing them to "fix" a medical issue, which is not always the case. Replacing the word "patient" with "individual" or "person" could reduce the negativity associated with the use of these medications. Another possible area for improvement is to use Layman's terms rather than medical jargon to make the article easier for anyone to understand. People with little to no knowledge of puberty blockers being able to read and understand the article is a good way to improve awareness and education on the subject. Ybramos (talk) 20:31, 30 July 2024 (UTC)

I think the edits do reflect language that supports diversity, equity, and inclusion. They use terms within their sections that I thought were inclusive. Many of the other edits were strictly informative, i.e., drug companies, drug names, chemicals, or mechanisms. With precocius blockers, I thought they used exclusively inclusive language, like "individuals" or "persons," and only used categorical words when reference another study that used that terminology. Areas of improvement would be to make it more lay-language. It can be difficult to read, so increasing accessibility in this way would be great. Htran2026 (talk) 22:48, 30 July 2024 (UTC)

Change to lead - banking the above discussion

Now that the hiccup of the major deletion is over (see [copyright problem removed]) and it would be a shame for all that constructive discussion to not be reflected in the page.

I will add now based on the consensus above in July:

• "As of 2024, several systematic reviews have failed to find conclusive evidence of significant changes in psychosocial health and levels of gender dysphoria. Long-term effects on fertility and cognitive development remain unknown"Peckedagain (talk) 12:05, 17 August 2024 (UTC)

Does the lead give too much focus to organisations who support it, (especially USA ones), than a balanced summary should? [I edited] to express the spread of views: "on one hand.... on the other' but that [was reverted] by Crossroads.

I will try another phrasing, and see what you think.Peckedagain (talk) 12:05, 17 August 2024 (UTC)

Change to lede

This is going to be a contentious topic and probably has been discussed on this page before, but I propose mentioning the fact that several systematic reviews have failed to find conclusive evidence about the potential psychosocial impact of puberty blockers. Mentioning that rising scepticism in the field of medicine has made puberty suppression the subject of public controversy is vague and doesn't do justice to the reasons why this is the case. Therefore, I propose adding at least a sentence along the following lines: Several systematic reviews failed to find conclusive evidence that puberty suppression improves psychosocial health in transgender adolescents. We may like to add reasons why this is the case (e.g., due to small sample sizes, heterogeneity of results, unreported data etc.), but at least some mention of the current research status in the lede is necessary for the balance of this article.

PS: I'll leave discussing whether or not we should make a distiniction on the basis of consensus-based and evidence-based support for puberty blockers up to others. Cixous (talk) 15:00, 12 July 2024 (UTC)

Yes it has been discussed a lot - see eg. https://en.wikipedia.org/wiki/Talk:Puberty_blocker/Archive_4#Cass_Review

I agree that this needs mentioning in the lede. Void if removed (talk) 15:23, 12 July 2024 (UTC)

Thanks for linking the previous discussion! I think there is enough of a case to mention it in the lede. We have Taylor et al. (2024) and Ludvigsson et al. (2023) who, broadly speaking, come to the same conclusion. Their findings aren't great news either - the Endocrine Society guideline from 2017 stated that there was low quality evidence for puberty suppression (p. 3 for those interested).

I'll give others some time to react as well, but if there's no major objection, I'll add it to the lede. Cixous (talk) 17:35, 12 July 2024 (UTC)

Yes, this is due - and overdue. The consensus-based vs evidence-based distinction seems close to the truth of the matter, but I’m not sure if RSes frame it that way Barnards.tar.gz (talk) 18:12, 12 July 2024 (UTC)

On the consensus-based vs evidence-based distinction: the best explanation thus far I've found is in the BMJ podcast episode with Hillary Cass, though I don't think this is the best source out there. It's a less than ideal situation, not in the least because being consensus-based is a tendentious claim that the medical organisations in question deny. Cixous (talk) 18:34, 12 July 2024 (UTC)

I would support a change to the lead that gives us a weightier summary of §Research status. I'd prefer to more closely match the section's language with something like "Several systematic reviews found that evidence of the effectiveness of puberty suppression in transgender adolescents is low in quality. As for the rest of the section, maybe something like "Critics of the reviews' methodology have said that high-quality evidence like randomized controlled trials would be unethical to obtain."? Firefangledfeathers (talk / contribs) 18:32, 12 July 2024 (UTC)

I wouldn't go for 'effectiveness', but stick closer to what the actual research articles are saying, i.e. 'psychosocial outcome' and/or 'cognitive effects'. After all, puberty suppression is effective when it comes to just that - puberty suppression. Phrasing it as a matter of effectiveness hopelessly obfuscates the matter. Lastly, I support adding a few sentences on critics, though I'm skeptical of 'randomised controlled trials' as proper criticism. No one is actually proposing giving one cohort of trans kids puberty blockers and others a placebo to see if mental health improves for the simple reason that this would never get past an ethics committee. Cixous (talk) 18:41, 12 July 2024 (UTC)

I prefer to go WP:LEADFOLLOWSBODY. Do you think the body needs to be adjusted, since it also mentions RCTs? You've sort of landed on the main point of the criticism there, since the upper tier is (at least according to the cited sources) reserved for RCTs. If I grade you on a 6 point scale but we all agree it would be unethical for you to get a 6, we probably haven't selected the best scale. Good point on effectiveness. How about "Several systematic reviews found that evidence supporting the use of puberty suppression in transgender adolescents is low in quality."? Firefangledfeathers (talk / contribs) 18:45, 12 July 2024 (UTC)

I understand where you're coming from, but I'd like to be as specific as possible here. A proper systematic review only synthesises high- or moderate-quality evidence, so stating that they found the evidence was 'low' is not what they did. If anything, it'd be appropriate to state the evidence was weak. As the most recent (and AFAIK only; could have gone into sexual development as well, but I forgot about that) specifically mention psychosocial outcomes and cognitive effects, I'd stick to being precise about that. That being said, I'm okay with writing things differently if that's what the majority of editors want.

On the adjusting of the body: I think the entire article could benefit from some rewriting (I'd even go as far as removing the entire 'political challenges' section, as it's practically geared to a US context). Discussions about RCTs have their place, but I think this criticism is missing the point. As Ludvigsson et al. (2023, p. 2288) points out: However, controlled trials do not necessarily require placebo treatment, but could for example build on the date or time of starting hormonal therapy to generate comparison group (i.e., controlled trials do not mean you have to deny participants endocrinological interventions). Cixous (talk) 19:02, 12 July 2024 (UTC)

Didn't the reviews synthesize high- or moderate-quality studies, but still find the evidence to be of low quality? Firefangledfeathers (talk / contribs) 19:14, 12 July 2024 (UTC)

You could phrase it that way, though I usually stick to high/low-quality studies and weak/strong evidence. That being said, I don't believe there's a right or wrong here. Cixous (talk) 20:12, 12 July 2024 (UTC)

Re choosing the right scale - we value RCTs because of their ability to distinguish the treatment effects from the placebo effect. If a treatment cannot be subjected to a RCT, that doesn’t mean the treatment gets an automatic pass - it means there is an upper bound to the certainty we can obtain. It’s possible that someone will figure out a way to do an ethical RCT for this treatment, and it’s possible that someone will find some other way to reject the null hypothesis. It’s also possible that we can’t find such alternatives, and only weaker evidence is attainable, in which case that upper bound on certainty would remain.

I am reminded of string theory - an attractive idea that has proven resistant to empirical testing. We might believe it to be impossible to test. If that were the case, the right stance would be to treat it as a provisional or tentative or hypothetical theory - with low certainty. The wrong stance would be to use a weaker form of empiricism (e.g. simulation), and treat the claim as true because it passed the weaker test. Barnards.tar.gz (talk) 19:22, 12 July 2024 (UTC)

That makes sense, though I wouldn't have said anyone's asking for a free pass, just a better measurement tool. To be clear, I don't think we need to hash it out. If we want to summarize the criticism present in the body, this seems like one chunk that gets enough weight for a lead mention. Firefangledfeathers (talk / contribs) 19:33, 12 July 2024 (UTC)

I'm fine with mentioning it in the lede, but we should make sure that it isn't presented as an argument against the systematic reviews. After all, the systematic reviews (especially Taylor et al.) do no object to the absence of RTCs, but to the absence of high-quality evidence with homogenous results. Cixous (talk) 20:15, 12 July 2024 (UTC)

Aren't the sources we're citing presenting this as an argument against the systematic reviews? Firefangledfeathers (talk / contribs) 20:49, 12 July 2024 (UTC)

I believe the current article represents it's sources somewhat ambiguously. The statement The use of puberty blockers for gender-affirming care has attracted some criticism, due primarily to the lack of randomized controlled trials within the research base doesn't reference any sources that criticise the lack of RTCs, but sources that state the use of RTCs is unethical. It would be more logical to phrase that as Scientists regard randomized controlled trials as unethical for testing the efficacy of puberty blockers. Again, I'd like to point out that this is a completely normal, even redundant thing to say, because an ethics committee would never approve of an RCT in this case. That doesn't automatically mean that you can't do controlled studies (i.e., including an untreated comparator group, such as adolescents on a waiting list/pre-post studies where you compare a treated group with patients who got to a clinic for their first meeting/non-gender dysphoric adolescents of the same age and/or social background). The NICE review (p. 45-46) actually criticised earlier studies for their lack of comparators while stating that RTCs may well be unfeasible.

The other major source for the Research status section is Cal Horton's analysis. Without going into major detail about their stance against the GRADE approach used by NICE, it is important to note that they criticise the NICE Review and the Interim report of the Cass Review, and not the commissioned systematic reviews. While the NICE reviews evidence for the purpose of healthcare recommendations, it is not a systematic review (as in, a meta-analysis).

So, to finally answer your question, the sources do not present it as an argument against the systematic reviews, but (a) they're somewhat unfortunately represented in the body, and (b) most of what they're saying isn't actually super revolutionary or even necessary. No one is actually saying (barring the nitwits at SEGM, obviously) that we should use RTCs, not even the systematic reviews. As a result, I don't feel mentioning criticism of emphasis on RTCs is a right move at all, because the systematic reviews aren't doing that and the sources critising RTCs do not pertain to these. Cixous (talk) 14:29, 13 July 2024 (UTC)

While the NICE reviews evidence for the purpose of healthcare recommendations, it is not a systematic review (as in, a meta-analysis).

The two NICE reviews were systematic reviews, and Zepf et al (2023) was a further update, following the same methodology but with more recent papers.

The whole RCT thing seems like a big red herring anyway - we know that the York systematic reviews found some moderate to high quality evidence, so this is not an insurmountable bar and nobody AFAIK is actually suggesting they're a requirement. Void if removed (talk) 15:44, 13 July 2024 (UTC)

Ahh, thanks for the clarification! I always thought that the NICE Reviews were reviews that were somewhat less strict than systematic reviews. You're also right about the RCT thing. Nobody is actually requesting this (not even the NICE Review). Cixous (talk) 15:48, 13 July 2024 (UTC)

You seem to have missed that the reviews contain explicit criticism of current research not meeting "double blind" levels of testing. -- Cdjp1 (talk) 21:26, 24 July 2024 (UTC)

Could you perhaps point me to a source that criticises the current research base for not being double blinded? AFAIK, it hasn't been the focus of criticism at all. The Cass Review mentions double-blinded RTCs as a gold standard, but does not state that they should or should not be used in studies on puberty suppression (p. 48-51). Taylor et al. (2024) makes no mention of double-blinded studies or RTCs at all. Ludvigsson et al. (2023, p. 2288) mentions randomised control trials, but sheers away from the use of a placebo and also notes that the research population is "highly vulnerable", but also doesn't mention double-blinded studies as a necessity. Cixous (talk) 15:17, 25 July 2024 (UTC)

I would support mentioning this if contextualized properly, something like Systemic reviews have found puberty suppression improves psychosocial functioning with a low certainty but noted that could be evidence it is effective in preventing dysphoria and associated mental health conditions from worsening due to incongruent puberty.

The research status section says the NICE review says 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. That specific conclusion was reiterated in the subsequent reviews cited. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:28, 12 July 2024 (UTC)

I'm all for contextualisation, but could you perhaps point me to where this specific conclusion was reiterated in Taylor et al. (2024) or Ludvigsson et al. (2023)? Cixous (talk) 14:30, 13 July 2024 (UTC)

Meant to say "review" - Zepf et al[1] say: 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.

But regarding the other two:

Ludvigsson et al 2023[2] said Psychosocial and mental health Table 2 outlines the six studies that examined psychosocial outcomes and cognitive effects.14–19 Three of these studies found significantly improved overall psychosocial function after GnRHa treatment as measured by the Children's Global Assessment Scale (CGAS).14–16 Two of these studies observed no statistically significant change in gender dysphoria.15,16 Two of these studies reported significantly improved self-rated quality of life after treatment measured through Kidscreen-27, Short Form-8 (SF-8), Child Behaviour Checklist (CBCL) (parent report), and Youth Self Report (YSR),16,17 while another study reported no statistically significant differences in anxiety and depression between those who started and not started hormone therapy.18 Because these studies were hampered by small number of participants and substantial risk of selection bias, the long-term effects of hormone treatment on psychosocial health could not be evaluated.

Taylor et al[3]: Regarding psychological health, one recent systematic review14 reported some evidence of benefit while others have not. The results in this review found no consistent evidence of benefit. Inclusion of only moderate- quality to high-quality studies may explain this difference, as 8 of the 12 studies reporting psychological outcomes were rated as low-quality

My two main concerns are

1. we contextualize that reviews are divided on how much weight to give the evidence. Some found "PBs improve mental health", other found "PBs don't seem to improve mental health / we're not super sure" - the dividing line being how much weight they give the low-quality evidence (and in medicine, low-quality evidence doesn't mean a treatment shouldn't be offered) - but nobody is in disagreement the underlying studies show mental health improvements.
2. We note "this keeps psychosocial health stable" could be evidence it's working by stopping worsening stress from an incongruent puberty as noted in the NICE review and Zepf et al

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:14, 13 July 2024 (UTC)

Systemic reviews have found… It would be misleading to frame the systematic reviews as having any positive finding. The key takeaway from all of these reviews is what they all agree on and all emphasise: the non-finding of conclusive or high-quality evidence. The it is plausible sentence you have quoted from NICE is only part of a passage which exists to outline that the range of uncertainty is great enough that it encompasses the possibility of positive effects. This is by no means an endorsement that the treatment improves psychosocial functioning with a low certainty. Barnards.tar.gz (talk) 09:33, 14 July 2024 (UTC)

Taylor et al[4]: Regarding psychological health, one recent systematic review14 reported some evidence of benefit while others have not

Equally important to the non-finding of conclusive or high-quality evidence is the finding of inconclusive or low-quality evidence.

Reviews say the evidence is inconclusive or weakly points towards benefits. We should reflect that. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:18, 15 July 2024 (UTC)

You are cherry picking positive-sounding studies and ignoring the actual conclusions of the papers you are citing. Proper weight should reflect the actual conclusions of the systematic reviews, to whit:

Zepf et al: Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn’t suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data.

Ludvigsson et al 2023: Results: In 21 studies, adolescents were given gonadotropin-releasing hormone analogues (GnRHa) treatment. In three studies, cross-sex hormone treatment (CSHT) was given without previous GnRHa treatment. No randomised controlled trials were identified. The few longitudinal observational studies were hampered by small numbers and high attrition rates. Hence, the long-term effects of hormone therapy on psychosocial health could not be evaluated. Concerning bone health, GnRHa treatment delays bone maturation and bone mineral density gain, which, however, was found to partially recover during CSHT when studied at age 22 years. Conclusion: Evidence to assess the effects of hormone treatment on the above fields in children with gender dysphoria is insufficient. To improve future research, we present the GENDHOR checklist, a checklist for studies in gender dysphoria.

Taylor et al: Conclusions There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

Your quote from Zepf omits the final sentence of the paragraph, which reads (modulo Google Translate): However, a control group would have been required to prove this possible effect of PB administration discussed here, so that such an interpretation can currently only be of a speculative nature. You are cherry-picking the part of the paragraph which makes it look like they found and endorsed a positive finding, but the final sentence makes it clear that they are (as with the NICE example I mentioned earlier) actually just illustrating the wide range of uncertainty, and that any positive finding would be speculative. It would be a gross misrepresentation of this study to falsely balance the headline conclusion of "significant conceptual and methodological flaws" with speculation.

None of these review papers see fit to mention the possibility of positive findings, even as low-quality findings, in their conclusions. The isolated low-quality studies are not "equally important" to the conclusion. It would therefore be a misrepresentation of research status to summarise as "evidence is inconclusive or weakly points towards benefits".

As something of an aside, I think a major conceptual flaw in play here is the idea that lots of low-quality evidence can add up to high-quality evidence. It's true that there are multiple studies purporting to show benefit. These are the ones that entities like WPATH like to point to to justify themselves as evidence-based. But it's just not true. All of those positive-sounding results - every single one of them - is completely consistent with a placebo effect. Particularly when the benefits are hard or impossible to measure objectively, the placebo effect can be very strong. These patients are getting treatment, and they're getting what they want, and they're getting the thing that they've been told will improve their lives. This is a perfect storm of placebo effect! It's actually remarkable that the studies showing marginally-positive benefits are only showing marginally-positive benefits. Under these conditions, results should be through the roof! That we only have low-quality studies weakly pointing to marginal benefits is damning with faint praise. Barnards.tar.gz (talk) 10:20, 20 July 2024 (UTC)

This debate is nonsense. The purpose of puberty blockers is not to cure gender dysphoria. The purpose of puberty blockers is to delay puberty so that transgender children, their parents, and their physicians have more time to decide if hormone therapy is appropriate. They are just a delay tactic since we know that puberty blockers are (more or less) safe for children, as we've been treating children with puberty blockers since the 1950s for precocious puberty (which isn't true for hormone therapy). No one cares if puberty blockers have a "positive effect" on gender dysphoria, depression, anxiety, anger or distress, as that is not what they are used for, so why are we talking about that? What people care about is: Do they successfully delay puberty? Are they safe? Do they have negative side effects? Those are the things we should include in the lead. Anything else is political propaganda. Nosferattus (talk) 14:19, 15 July 2024 (UTC)

See Cass p173-180 for a discussion of the various intended benefits of using puberty blockers. It’s not just “time to think”. It is reasonable to assess the evidence for whether or not the intended benefits are achieved. Barnards.tar.gz (talk) 15:59, 15 July 2024 (UTC)

Taylor et al[5]:

1. Rationales for puberty suppression in the Dutch treatment protocol, which has informed practice internationally, were to

1. alleviate worsening gender dysphoria,
2. allow time for gender exploration, and
3. pause development of secondary sex characteristics to make passing in the desired gender role easier.6

1. Practice guidelines propose other indications for puberty suppression, including

1. allowing time and/or capacity for decision-making about masculinising or feminising hormone interventions, (which is really just 1.2 repeated another way)
2. and improving quality of life. 4 7 8

Absolutely none of those contradicts Nosferattus's statement.

It is reasonable to assess the evidence for whether or not the intended benefits are achieved. - the intended benefit is delaying puberty so you're not forcing a kid through an incongruent puberty as you deny them hormones. It is not to cure their GD and not a single source says it does.

What people care about is: Do they successfully delay puberty? - this 100%. If we're going to toss in some reviews say it keeps mental health stable, others say it improves it, others say it inconclusively improves it - then we've got to include the note that GD is known to worsen due to incongruent puberty. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:27, 15 July 2024 (UTC)

I’m with Nosferattus’ point, puberty blockers don’t exist to make things better, they exist to keep things from getting worse. Expecting otherwise is placing undue onus on them that HRT is more responsible for. Snokalok (talk) 17:51, 20 July 2024 (UTC)

You’re describing a benefit of the treatment. The systematic reviews are clear that there is no high quality evidence that this benefit exists. To be clear, this doesn’t mean the benefit definitely doesn’t or absolutely can’t exist - it just means there is no high quality evidence for it. To return this thread to @Cixous’s starting point:- this lack of high quality evidence is the reason why some countries are going cold on the treatment, and it does our readers a disservice to be vague about this. Barnards.tar.gz (talk) 19:40, 20 July 2024 (UTC)

Are you saying there is no high quality evidence that puberty blockers delay puberty? Nosferattus (talk) 02:41, 21 July 2024 (UTC)

No, there is no dispute that puberty blockers do delay puberty. The dispute is over whether this delay constitutes a benefit. Barnards.tar.gz (talk) 07:12, 21 July 2024 (UTC)

As previously discussed, per best available MEDRS there is no clearly agreed rationale for this treatment, so the standard by which it is deemed a "success" is also unclear. Void if removed (talk) 07:51, 21 July 2024 (UTC)

Thanks for bringing back the discussion to its actual topic, @Barnards.tar.gz. I suggest adding the sentence I initially proposed (see above). If anyone feels like more contextualisation is necessary, they can start a new/different discussion about that. For now, a clear vote in favour of or against mentioning the findings of the review would be great.

PS: sorry for the late reply. My laptop sadly crashed :/ Cixous (talk) 17:08, 23 July 2024 (UTC)

My vote would be against as it misleadingly implies that puberty suppression is intended to improve psychosocial health in transgender adolescents (rather than simply a means to delay the use of transgender hormone therapy). Nosferattus (talk) 21:39, 23 July 2024 (UTC)

Perhaps Several systematic reviews failed to find conclusive evidence that puberty suppression benefits transgender adolescents would be better? Barnards.tar.gz (talk) 08:20, 24 July 2024 (UTC)

I'm not disputing that puberty suppression was (partially) intended for assuring gender dysphoria would not worsen, but it has an impact on associated symptoms (e.g., depressive symptoms, anger/anxiety issues etc.). Part of what made puberty suppression so appealing was its positive, reductive effect on associated symptoms [1]. As someone else pointed out, a point of controversy arose when GIDS was unable to replicate these findings about psychosocial health and gender dysphoria.

Gauging psychosocial health is standard in clinical trials focusing on puberty suppression, because it tells researchers whether or not their rationale (not worsen psychological stress) actually works even when gender dysphoria remains at the same level. To call a focus on psychosocial health a misleading implication, seriously misses the point of what studies have been measuring over the past decade.

@Barnards.tar.gz: I'm not sure how to feel about your compromise. I'd like to stay as close to the source as possible and be as clear as possible, so I'd rather say psychosocial health and unclear effects on gender dysphoria when the sources state that. Cixous (talk) 14:09, 24 July 2024 (UTC)

@Cixous: Your suggested wording doesn't say "not worsen"; it says "improves". And if we're talking about not worsening, the reviews support the conclusion that puberty blockers (or at least GnRH analogues) do not worsen gender dysphoria, anger, or anxiety, and there is low quality evidence that it may reduce depression. Here's what the NICE review says specifically in its Results section:[6]

• Impact on gender dysphoria: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect gender dysphoria.
• Impact on mental health: depression: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, may reduce depression.
• Impact on mental health: anger: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect anger.
• Impact on mental health: anxiety: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect levels of anxiety.

So if you really want to "stay as close to the source as possible", how about: Systematic reviews have found that puberty suppression in transgender children and adolescents, prior to starting gender-affirming hormones, has no significant effect on gender dysphoria, anger, or anxiety, but it may reduce depression. Nosferattus (talk) 03:38, 25 July 2024 (UTC)

That's a fair point. Do you have any references from the York review and/or Ludvigsson et al. that support that puberty suppression may reduce depression? If so, I'm fine with the way you prhase it. Cixous (talk) 14:54, 25 July 2024 (UTC)

Taylor et al says:

No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility.

Void if removed (talk) 15:22, 25 July 2024 (UTC)

Thanks Void! I propose the following: As of 2024, several systematic reviews have failed to find significant changes in psychosocial health and levels of gender dysphoria. Long-term effects on fertility and cognitive development remain unknown. Cixous (talk) 15:30, 25 July 2024 (UTC)

That seems like a decent summary for the lead. Maybe we should start an Efficacy section in the body for more detailed discussion. Nosferattus (talk) 01:03, 26 July 2024 (UTC)

Thank you! I'll give users some time to object to it, but if there is no objection, I'll add it tomorrow. I also agree that an efficacy section is due. Maybe it can be a subsection of a (rewritten) research status section?

PS: I think the lede may benefit from further clarification on the divergent reasons of US states versus European countries being more cautious about puberty suppression. I remember a European Academy of Paediatrics policy statement going briefly into this a few months ago. This addition is another discussion though, that we may want to get into after adding this text into the lede. Cixous (talk) 17:48, 26 July 2024 (UTC)

This fails precision, so it would immediately get a Template:Quantify tagged on it. How many systemic reviews were there that concluded this specific outcome? Were there others other than the Cass Review? Raladic (talk) 18:01, 26 July 2024 (UTC)

From the top of my head: the NICE Review, Taylor et al. (2024), Ludvigsson et al. (2023). I'm not sure if Zepf et al. (2023) goes into long-term effects, but it reaffirms the NICE Review conclusions. Cixous (talk) 18:07, 26 July 2024 (UTC)

So then we should potentially say three, not several if it's clear all 3 concluded the exact same thing. The lead has to summarize what the article body says, but currently the Puberty blocker#Research status section only discusses the NICE review in detail with a by-sentence of the Cass review having a "similar" conclusion, which isn't the same as the very specific conclusion that the sentence implies, so instead it would have to be softened since the sentence implies that all of them concluded the very strongly worded same conclusion.

The proposed sentence also leaves out the criticism from notable other trans medical organizations, such as WPATH, so it would fail WP:NPOV by only summarizing one side, without the other. Raladic (talk) 18:15, 26 July 2024 (UTC)

I'm fine with adding a sentence on WPATH, but I feel we should try to steer away from bothsideism. It is completely fine to mention the WPATH stance on this, but we shouldn't make it seem as if reaffirming that the evidence pool is actually high-quality makes a systematic review redundant. I think the best way we can go here is to highlight a disagreement between evidence-based and consensus-based evidence aggregation.

PS: It actually makes 4 systematic reviews then, not 3.

PS: Sorry for the late reply. I seem to have gotten myself involved into a series of unfortunate events. Cixous (talk) 07:48, 4 August 2024 (UTC)

I'm currently traveling, so I can't research it myself, but I'm curious what the other reviews (besides NICE) have to say about depression. Nosferattus (talk) 18:29, 26 July 2024 (UTC)

It looks like Taylor et al consider the evidence on depression to be "moderate" rather than high quality. Thus they ultimately dismiss it in the conclusions. Ludvigsson et al. combine the various studies for statistical analysis and find no significant difference in the combined data. Since NICE and Taylor et al do actually report evidence of significant changes regarding depression, just not high quality evidence, I think we might have to add a caveat to any lead summary (similar to Cixous's original proposal), i.e. … systematic reviews have failed to find conclusive evidence of significant changes in psychosocial health …. Nosferattus (talk) 00:34, 28 July 2024 (UTC)

That would be nice actually. It does not mean that the desired effects of puberty blockers do not exist, but simply that it can't be deduced from the current evidence base. Would the originial proposal I made do? Cixous (talk) 07:51, 4 August 2024 (UTC)

No, as I mentioned before there are problems with the framing, for example, "failed to find" rather than "did not find" and "improves" rather than "significantly changes". Also, I don't think it makes sense in the lead. It should be added to the "Gender dysphoria" section to provide balance with statements about systematic reviews that did find positive effects on psychosocial health, e.g. Rew et al. If we put it in the lead it makes the article sound contradictory: the lead and the "Gender dysphoria" sections would say opposite things since they are talking about different reviews with different conclusions. We need to flesh out the information in the article body before we add more content to the lead, IMO. Nosferattus (talk) 23:46, 4 August 2024 (UTC)

I get where you're coming from adn we can meet each other at the middle in this case. I'm also all for adding a (more detailed) discussion of the reviews to the 'gender dysphoria'/'research status' section, but I still think including it in the lede is warranted considering multiple systematic reviews have come to more or less the same conclusions. Perhaps a joint approach is an idea (i.e., adding info to the 'gender dysphoria' section and the lede simultaneously)?

PS: Could you please link Rew et al.? Haven't read that one :). Cixous (talk) 17:51, 6 August 2024 (UTC)

Rew et al. is available on Sci-Hub, but the spam blacklist won't allow me to link to Sci-Hub. The more I read all these reviews, the more it seems apparent that the main difference is how high the review sets the bar for evidence. Hopefully we can explain that in the text so that it doesn't sound like these reviews are just contradicting each other. Nosferattus (talk) 18:53, 7 August 2024 (UTC)

(sorry for the late reply ://).

Yeah, I agree with giving weight to different systematic reviews in the body. I do not deny a focus on the body is ideal, but I believe that there is consensus to justify mentioning the research status in the lede. Cixous (talk) 09:09, 23 August 2024 (UTC)

• @Cixous @Barnards.tar.gz @Nosferattus Uninvolved editor here...

Before you all continue: I had to rollback to a May 12th version of the article due to copyright violations. Also be aware: there are going to be students working on this article soon.⸺RandomStaplers 05:43, 25 July 2024 (UTC)