Talk:Puberty blocker/Archive 1

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Wiki Education Foundation-supported course assignment

This article is or was the subject of a Wiki Education Foundation-supported course assignment. Further details are available on the course page. Student editor(s): Nor'bro 123.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 02:50, 18 January 2022 (UTC)

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 26 August 2020 and 18 December 2020. Further details are available on the course page. Student editor(s): Aidepikiw3000.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 02:50, 18 January 2022 (UTC)

Other uses?

Are there other uses besides trying to perform a "gender change"? I would assume there would be, and that the article is giving undue weight to a controversial elective procedure which is not the treatment's primary use. — Preceding unsigned comment added by 24.207.136.200 (talk) 03:49, 9 November 2014 (UTC)

• Puberty blockers are primarily used in the case of precocious puberty; that is their main function re. the article topic. That's clearly mentioned in the lede, while the next paragraph involves their clinical usage in dealing with children with GID. I'm not exactly seeing the undue weight here. Since the article is specifically about blocking puberty, it doesn't go into details on where medicines like Leuprorelin and Nafarelin are primarily used in treating cancers that are exacerbated by sex hormones, like ovarian or prostate cancer. - Alison ^❤ 02:14, 12 November 2014 (UTC)

Recent revert

@Kabahaly: I thought you were restoring a different edit here, and so my edit summary probably doesn't make much sense.

Nevertheless, I still would have reverted here because the edit appears to mis-characterize the conclusion of the study:The study authors conclude that "there is no actual change in BMAD or tBMD in young transgender adolescents on long term GnRHa therapy". I don't really know where the editor is getting the 95% figure. Nblund ^talk 16:09, 10 July 2019 (UTC)

Citation needed tag

@James Cantor: I'm a little confused as to what you're looking for with this this CN tag. It comes from a policy statement from a respected medical organization, and it cites three separate studies to support the claim. I'm confused as to why you're removing a citation in order to add a citation needed tag, since this seems like a straightforward interpretation of a MEDRS. Nblund ^talk 15:18, 2 September 2019 (UTC)

Yes, it indeed came from a policy statement. It did not come from research. FWIW, that policy statement itself is riddled with factual errors and rather blatant misrepresentations of what others have said. I list them here: http://www.sexologytoday.org/2018/10/american-academy-of-pediatrics-policy.html. Rafferty does indeed meet WP standards as an RS, but what that document expressed was that committee's political opinion. The specific claim of the effects of puberty blockers was not based on research, and Rafferty did not cite any (unless I've missing it).— James Cantor (talk) 15:45, 2 September 2019 (UTC)

I'm assuming you're objecting to the psychological wellbeing stuff, right? The reduced need for surgeries thing seems like it is kind of self-evident. The statement includes footnotes, I eliminated them from the quote, but they're available in the article. Here are the four studies cited:

• Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129(3):418–425pmid:22351896
• Olson J, Garofalo R. The peripubertal gender-dysphoric child: puberty suppression and treatment paradigms. Pediatr Ann. 2014;43(6):e132–e137pmid:24972421
• de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276–2283pmid:20646177
• Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1413–1423pmid:18981931

WP:MEDRS notes "guidelines or position statements from national or international expert bodies" are ideal sources for this kind of thing. Nblund ^talk 15:56, 2 September 2019 (UTC)

Of those studies, only deVries would work. Spack did not give any data on outcomes at all; they merely described their incoming patients. Olson mentions "preliminary data" as a justification for their recommendations, but does not provide that data. Wallien is not about puberty suppression at all; it is about post-pubescent kids (age 16 and up).— James Cantor (talk) 16:12, 2 September 2019 (UTC)

Okay. You should cite other ones then. This is also supported by the the Endocrine Society guidelines: Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains (86) A slightly older review in the Lancet is a bit more circumspect, but still concludes that The few studies that have examined the psychological effects of suppressing puberty, as the first stage before possible future commencement of CSH therapy, have shown benefits. Unless you have something more substantive than your website, I don't think there's much here to go on. The standard is WP:V not truth. Nblund ^talk 16:29, 2 September 2019 (UTC)

I think you are missing my point. It is entirely true that various associations have included that policy, but it is not true or verifiable that THE RESEARCH says it. That clinicians and their professional associations are speaking beyond the data is what much debate is about. I think it would be better (both verifiable and true) to change the sentence to indicate that this is professional opinion rather than a research result. (As I said, deVries is the only actual study which suggests a beneficial effect, but it was a pre/post study with no control group. That study says only that kids post- blockers were less distressed than pre- blockers, but because many other things change in these kids lives during transition, we can't know which changes produced which effects.)— James Cantor (talk) 20:05, 2 September 2019 (UTC)

No, we're not just talking about "policies", the three sources quoted all say that the research says this. WP:V says that statements should come from reliable sources, and that standard has been met here. I understand that you believe they are mis-characterizing the existing research, and you could be right, but Wikipedia isn't the place to correct the record. We cant discount high quality sources based solely on your word. Nblund ^talk 20:25, 2 September 2019 (UTC)

Neutrality warning/omitting endometriosis use of these drugs

I had added to the intro that these drugs have been used to treat endometriosis for decades (with of course reference) and it was removed by another user... Why? This use is FDA approved, and it is controversial, nevertheless, because of the side effects on women.

The page is including, in the other hand off-label/non-FDA approved use of this drugs for short height kids in the same intro.

Are we on purpose trying to hide known side effects of these drugs?

I am adding endometriosis use in the intro again... for neutrality... Algalindoo (talk) 23:56, 2 February 2020 (UTC)A

Stick to WP:MEDRS-compliant sourcing. Flyer22 Frozen (talk) 01:25, 4 February 2020 (UTC)

Endometriosis use erased twice by same user/POV

I don't see why a user is obssessed with hiding the most widespread use of these drugs: endometriosis.

I am adding it again, with a different source, if the problem "was the source" then the appropriate thing to do is to flag the source, not to erase endometriosis + my comment here.

The most likely cause is that the user wants to hide the known side effects of the drug. — Preceding unsigned comment added by Algalindoo (talk • contribs) 02:43, 4 February 2020 (UTC)

Algalindoo, and now I see that you added this and this. Read Template:POV. An article does not become POV simply because you don't like it. And I'm not obsessed with anything regarding this topic. Nor am I trying to hide anything. You are a newbie who is not listening. I will alert WP:Med to this. And do stop creating talk page sections at the top; per Wikipedia:Talk page guidelines#Layout, newer sections go at the bottom. There was also no need for you to create another section just to comment again. Flyer22 Frozen (talk) 02:45, 5 February 2020 (UTC)

The lede of the article has strayed off the topic of the article. I suggest that the material on endometriosis and sex offender recidivism (and other topics) is moved to Gonadotropin-releasing hormone agonist#Medical uses, and that the lede also indicate that compounds other than Gonadotropin-releasing hormone agonists can be used for the purpose of blocking puberty. For example, looking at the bottom of the current article: The combination of bicalutamide, an antiandrogen, and anastrozole, an aromatase inhibitor, can be used to suppress male puberty as an alternative to GnRH analogues. Klbrain (talk) 09:36, 5 February 2020 (UTC)

Agree with User:Klbrain. This article is about medications when used to block puberty. Not when the medications are used for other stuff. We have other articles. Doc James (talk · contribs · email) 11:33, 5 February 2020 (UTC)

also agree w/ Klbrain--Ozzie10aaaa (talk) 20:35, 9 February 2020 (UTC)

That was not clear from the article. I've changed the introduction to be clearer. WhatamIdoing (talk) 17:03, 6 February 2020 (UTC)

noteworthy this is not balanced and critique is gone

The critique was valid and puberty blockers were referred as chemical sterialisation of children within journals. — Preceding unsigned comment added by 146.200.183.53 (talk) 18:42, 18 September 2018 (UTC)

Calling puberty blockers "chemical sterilization" is absurd nonsense. Putting aside the fact that cited source didn't even come close to a WP:MEDRS, the statement wasn't an accurate reflection of the source. The article states: puberty blockers followed by (or used concurrently with) cross-sex hormones to prevent the “wrong puberty” in prepubertal kids results in irreversible sterilization. It is true that people who take puberty blockers followed by cross sex hormones do see reduced fertility, but puberty blockers alone are reversible, and doctors don't prescribe cross-sex hormones unless they believe a person has a firm desire to transition and is old enough to be capable of making informed decisions about their bodies. [[User:Nblund |<span style="background-color:

This is incorrect. as a professional in the medical industry i could provide the medwatch reports that cite the massive endocrine issues caused by these drugs in EVERYONE including children. (and many (not all) of the drugs cause massive problems of osteoporosis.) All of this can been seen and is even explained in the risk assessment/mitigation paperwork submitted to the FDA. I cannot link to the data as it requires a login to the FDA site. However copies can be obtained via FOIA requests. This paperwork also contains the RBAs (risk benefit analysis) for each adverse effect known for approved uses. In the RBAs these effects are discussed openly and without concealment. That said there are ZERO drugs that are currently approved use as puberty blockers, there were a few intended for dealing with dangerous early puberty (think a 4 year old kid) but they were all reassessed as too dangerous for use and rejected as the RBAs were not sufficient. I dont know how to cite a hard FOIA request or a medical professional only link as a source. If someone does, please know they can find all of that information very easily with the FDA. These are ALL very dangerous drugs, and the promotion of off label uses is irresponsible. — Preceding unsigned comment added by 50.204.42.253 (talk) 00:10, 23 October 2019 (UTC) As a side note, the reason puberty in a 4 year old kid is dangerous is the hormone spike is out of phase with the parallel processes i mentioned earlier. This is similar though not identical to the risk encountered when blocking hormones during "puberty". The processes are set out of phase. — Preceding unsigned comment added by 50.204.42.253 (talk) 00:28, 23 October 2019 (UTC)

1. CC79A7; color:white;">Nblund]] ^talk 19:18, 18 September 2018 (UTC)

The source from American Association of Pediatrics is authoritative, but doesn't provide evidence. We should provide a study or other evidence indicating that blockers are safe, which is known at least for children with early-onset puberty 2601:602:9400:3C70:9C19:32D7:93BC:5AA9 (talk) 09:33, 13 January 2019 (UTC)

There is criticism of puberty blockers, but it often concerns what is currently found in the "Effects" section. With regard to WP:MEDRS, the guideline strongly discourages primary sources and prefers secondary and tertiary sources instead. As for including information that is not WP:MEDRS-compliant, that is allowed when it comes to a WP:MEDMOS "Society and culture" and/or "History" section. See what WP:MEDDATE states about history sections, for example. If material is fringe, it's probably best avoided, but WP:Fringe does allow some leeway for fringe views. Flyer22 Reborn (talk) 20:10, 18 September 2018 (UTC)

References

Sorry - I don't know how to do this but - seems not objective ref: Puberty Blockers. Below is from BBC Newsnight. Why have they been controversial?

Legal action being launched against the Tavistock and Portman NHS Trust, which runs the gender identity clinic, focuses on whether children can give informed consent to treatment with puberty blockers.

Puberty hormones are linked to changes not just in the body but also in the brain.

Gids says that it is not yet known whether puberty blocker treatment "alters the course of adolescent brain development".

It also says that the full psychological effects of the blocker are not yet known.

Some early data from one study showed some taking the drugs reported an increase in thoughts of suicide and self-harm but it was unable to say whether it was the drugs or something else causing the increase.

Experts on clinical trials criticised the design of the study but said the data warranted further investigation.

NHS England says, in its clinical guidelines, that research evidence around the long-term impacts of puberty blockers is "limited and still developing". Appologies if I'm breaking protocol here. This is why I've posted on Talk page. — Preceding unsigned comment added by 90.219.212.175 (talk) 14:49, 7 July 2020 (UTC)

BBC Newsnight is not an accurate source but was a biased program. For example, the puberty blocker has been in use with young transgender people since 1993. The idea that it is an experimental drug for treating patients with gender dysphoria is inaccurate. Furthermore, suggestions that the puberty blocker is easily available were inaccurate because between 2015-2020 there were 11,444 referrals to Tavistock GIDS out of which only 161 patients were prescribed the puberty blocker. Claims of a social contagion are inaccurate too because using 0.3% as a conservative estimate of the population who are transgender translates in the UK teenage population as 22,830. Therefore, what we should be asking is why are the number of referrals so low?

Suicide in trans people is largely caused by two factors, 1) isolation caused by societal prejudice - including rejection from family and friends, 2) denial of access to healthcare through gatekeeping, GPs who refuse to treat transgender patients, and waiting lists in excess of 5 years for an initial appointment followed by multiple years for a secondary appointment - for example a child referred to Tavistock after the age of 12 will not see anyone from Tavistock but will be referred to adult services at the age of 17 and will then have to start again from the back of the queue - meaning that some people have been waiting 9 years and still have not had a first appointment, in the meanwhile no support is offered to help the patient cope with intense gender dysphoria. NOTE: fear of coming out as transgender is also a major factor of suicide related to the first reason. There are massive failings in the NHS in the provision of gender related healthcare including blatant transphobia, out of date practices, incomplete gender affirming healthcare, and massive waiting times.

Proposed Edit/Addition

I would like to weigh in on a proposed edit that can enhance the information about puberty blockers. A lot of past and recent research with puberty blockers have been done with patients diagnosed with Gender Dysphoria or that identify as being Transgender. I have several research studies, news articles, and literature reviews that support this piece of information. I think identifying the target population of Puberty Blockers is vital in understanding this medical method. I also think it is pertinent in the world we live in today to accurately represent all specific patients in the medical field. Nor'bro 123 (talk) 00:15, 10 April 2017 (UTC)

The article states that the effects of puberty-blocking drugs are reversible, with a specious footnote that indicates no such thing. 5 minutes of internet research will tell you that the point is controversial. This is way beneath the standards of Wikipedia. — Preceding unsigned comment added by 158.228.48.1 (talk) 03:16, 30 June 2017 (UTC)

It is basic knowledge among professionals that the effects of puberty blockers are completely reversible; only the lay public does not know this. The controversy is artificial and stirred by dishonest bigots who hate transgender people and wilfully spread disinformation and hateful propaganda (manufactured controversy, concern trolling). "5 minutes of internet research" that consist of watching YouTube videos and reading blog posts by known bigots and fake "concerned citizens" are what is really "specious" and "way beneath the standards of Wikipedia". I have replaced the ref with a suitable one (though it is behind a paywall). --Florian Blaschke (talk) 16:19, 9 August 2017 (UTC)

This is incorrect. GnRH antagonists do NOT pause puberty, what they do is prevent the hormone spike from having an effect. The issue is that this hormone spike is limited in duration and tied to many other biological effects that run in parallel. If a person on GnRH antagonists misses that hormone spike, they miss it. if they miss part of it, then that part is missed. As such keeping an adolescent on GnRH blockers though their development will result in either a missed portion of puberty, or missing all of it. It is however TRUE that stopping the GnRH will result in the remaining hormonal spike having effects, but the result is a partially missed puberty. Taking hormones after the fact will not address this, as the parallel processes especially the ones related to bone development have all ready happened. The result is likely to be decreased bone density. This means that while a patient could still "go through puberty" it would be a partial puberty set out of phase. I don't have any credentials to discuss potential mental effects. — Preceding unsigned comment added by 50.204.42.253 (talk) 00:23, 23 October 2019 (UTC)

calling editors derogatory names and making accusation is an effort to stifle the pillars of this project. This article would NEVER pass MEDERS standards and I really have to wonder why this kind of crap is left untouched by editors who regularly jump on every edit by a "medical lay person" who attempts to edit a medical article. OH-and I guess this dr has some kind of "agenda? or would that be OR-(rhetorical, yes it would) http://www.spiked-online.com/newsite/article/its-not-transphobic-to-question-transgenderism/19353#.WIk4j4VFxjo Call me a "concern troll" because I am very concerned TeeVeeed (talk) 23:09, 23 August 2017 (UTC)

Everyone who thinks/knows otherwise is just "laypeople".......very telling — Preceding unsigned comment added by 70.68.165.139 (talk • contribs)

Interesting analysis of Tavistock gender clinic's use of puberty blockers. It raises serious concerns about the reversibility of puberty blockers, and their long term effects on a person's sexual development. This wiki page seems contrived to downplay any perception of risk. http://users.ox.ac.uk/~sfos0060/Biggs_ExperimentPubertyBlockers.pdf — Preceding unsigned comment added by 112.118.37.71 (talk) 07:46, 28 July 2020 (UTC)

In an effort to address the controversy surrounding the use of puberty blockers as a treatment for transgender children, I plan to add a Society and Culture section with the subsection “Ethical and Legal Issues.” This section will note the differences of opinion amongst scholars pertaining to the ethics of puberty blockers. This section will also take note of proposed legislation in the United States that challenged access to puberty blockers, as well as a lawsuit in the UK that sought to prohibit the use of puberty blockers as treatment for minors. Additionally, I plan to move the part of the lede regarding the use of puberty blockers to treat precocious puberty and short stature to the Medical Uses section. I plan to do this so that the lede more accurately outlines and addresses the sections of the article, as there is no full section dedicated to these aforementioned uses of puberty blockers. annotated sources used in research Aidepikiw3000 (talk) 07:14, 7 December 2020 (UTC)

Where is the source for this statement?

Significant data suggests that the use of puberty blockers increases the quality of life for transgender children,

I have tagged it as citation needed. Ernestrome (talk) 14:36, 26 March 2021 (UTC)

I have found several papers referenced for psychological help in reference 14 [1], quoted extensively on this page, but I do not see that they support this statement. I found 3 studies quoted there. One is the Dutch study, ref. 15 [ https://dx.doi.org/10.1080/00918369.2012.653300 ], but note Ref. 29 [2] could not reproduce it (Ref 29 lists other papers that did and didn't, it seems not yet to have reached consensus in the literature). A few other statements in Ref 14 ([2]) about good outcomes, i.e., to refs 34, 36, are also to the Dutch study (one is to a review which then goes to the Dutch study). And again, the people in the Dutch study had significant restrictions to qualify for joining, so it is not clear if their results would be expected to be generally applicable. Another reference for good outcomes is [3] which was challenged for being statistically inadequate (P=0.14 > 0.05 as required for significance) by [4], referenced in a refereed article here. The third reference is to [5] which doesn't, although the referring article says it does, say what the outcomes are from puberty blockers. This last paper is a study of who was seen at the clinic. It ends with "Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation." That is to say, I don't think ref. 14 supports it. Thanks. Jdbrook (talk) 00:14, 27 March 2021 (UTC)

Agreed. Suggest editing it to say "although it has been suggested that puberty blockers may improve quality of life and reduce harms for transgender children, only preliminary data are available... Ernestrome (talk) 10:03, 27 March 2021 (UTC)

Where is source for this statement?

While some studies suggesting the benefits of using puberty blockers to treat transgender youth have been critiqued for systematic errors or a lack of transparency, the vast majority of research has not been subject to such criticism.

Thank you. Jdbrook (talk) 16:22, 25 March 2021 (UTC)

Is it in here or did you check it already? [6] Crossroads ^-talk- 05:25, 26 March 2021 (UTC)

Hi, thanks a lot. I couldn't find it in there, indeed that is the nearest reference. That paper lists pros and cons, the title is, after all, "Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents." There is no statement about the "vast majority of research not being subject to.." that I could find, or that one side of the dilemma outweighs the other. It lists a lot of concerns and concludes with "on the one hand such and such, on the other hand, such and such...", here is some of it, including the beginning and end of the concluding paragraph/conclusion.

I hope that this brief excursus has clarified the supporting and opposing arguments with respect to the use of hormone blockers to suppress puberty.[..]From a psychological perspective, the main dilemma is to understand whether buying time at such a precocious age truly enables children to explore deep personal meanings, or whether it freezes youngsters in a prolonged childhood, secluding them from certain aspects of reality and isolating them from peer groups. This is a rather difficult issue to confront in quantitative follow-up studies (which of course are crucial for monitoring physical and psychological outcomes). Thus, qualitative and clinical studies may have a great deal to offer, especially when conducted by expert clinicians who know these children very well. In any case, as for many other aspects of gender identity development, it is crucial that a person-by-person approach is adopted (as performed by the abovementioned gender clinics) to tailor effective and appropriate interventions according to individual needs.

Perhaps I am not searching correctly, but I could not find it. Thanks a lot. Jdbrook (talk) 23:42, 26 March 2021 (UTC)

If you read it and it's not in there, then just remove it as "failed verification". I'm not seeing it based on the above, but I didn't read the paper. Crossroads ^-talk- 06:57, 27 March 2021 (UTC)

I'll give it another read through and if I still can't find it in the source, I'll remove. Thank you. Jdbrook (talk) 23:04, 27 March 2021 (UTC)

question about wording for fluctuating gender identity

Hi, @Equivamp:, I believe the statement about "gender identity is still fluctuating at this age" is supported by the next sentence, drawn from the same review:

"around 70-90% of children who have GD grow out of it without medical intervention,[14]"

Does it read like this to you? Thanks. [[User: Jdbrook]] talk 04:29, 1 April 2021 (UTC)

No, I don't think that text supports the statement that gender identity is fluctuating in adolescence. Equivamp - talk 08:20, 1 April 2021 (UTC)

The next sentence says that most childhood onset people grow out of GD (the timing is that it tends to happen before or during puberty). Adolescence begins when puberty starts, so there are adolescents who are growing out of their GD. I took that to mean that their identity was fluctuating, i.e. changing. (If you mean fluctuating means going back and forth, then I haven't read studies of that.) How do you read the growing out of GD sentence? Thanks. Jdbrook talk 04:08, 2 April 2021 (UTC)

If the first sentence means the same thing as the second, then it should be removed, because there's no reason to have two versions of the same sentence when the second states its meaning better and more clearly. However, I don't think that is the case, because the source presents them as separate arguments: the first sentence, about "fluctuating" gender identity refers to 1) the ability to diagnose GD in adolescence with certainty, and 2) the inhibition of gender identity development, while the second sentence refers to rates of desistance.

Now that I have had time to look more into the source, it becomes more clear that the first sentence is not being made in the author's, but instead merely stating the primary arguments. For example, it sources the quote spontaneous formation of a consistent gender identity, which sometimes develops through the "crisis of gender" to a 2007 research article by Giordano, where the quote in full says (emphasis in original): In other words, in theory, blockers may inhibit the spontaneous formation of a consistent gender identity, which sometimes develops through the 'crisis of gender', a position which the author attributes to the British Society of Paediatric Endocrinology and Diabetes, and then immediately argues against. So the source in the article is citing a source describing an argument to itself describe the argument.

Also, now that you have brought the sentence you've quoted to my attention, I notice something: the phrase grow out of it is not used by the source, and to me it seems unencyclopedic and less than neutral. I don't think it's in line with the source, nor most sources on the subject of resolved GD in children, which as the source notes, tends to describe it in terms of "persistence" vs "desistence". The source also doesn't support, "without treatment", at best it supports without "somatic treatment". So I'm going to change that. --Equivamp - talk 01:00, 3 April 2021 (UTC)

synth question

@Equivamp: This quotation is directly from the source. The two sentences are adjacent in the source and there is also discussion elsewhere in the paper. Here is the reference:[ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243894 ]

“We found no evidence of change in psychological function with GnRHa treatment as indicated by parent report (CBCL) or self-report (YSR) of overall problems, internalising or externalising problems or self-harm. This is in contrast to the Dutch study which reported improved psychological function across total problems, externalising and internalising scores for both CBCL and YSR and small improvements in CGAS [24]. ”

Can you please explain what the synthesis question is? Thanks. Jdbrook talk 03:05, 3 April 2021 (UTC)

@Jdbrook:, I don't want to speak for Equivamp, but I believe the only objection is the word, "but", in this snippet:

...it does not persist after puberty,[15] but almost all (98%) ...

Who made the connection between those two assertions represented by that "but": you, or one of the authors of one of the articles who referenced the other article? If it was you, then no "but". Mathglot (talk) 03:15, 3 April 2021 (UTC)

Aha. Thank you. Now I understand. That was me. I have read the two contrasted together, there are other statements of this in the literature, but they may not have a Wikipedia appropriate reference. I will fix that. Thanks. Jdbrook talk 04:57, 3 April 2021 (UTC)

Yes, that was the extent of my edit, thanks Mathglot. Equivamp - talk 08:29, 3 April 2021 (UTC)

Primary sources need to be replaced

I just undid one recent edit because it was a primary source, and replaced it with a survey article that is MEDRS-compliant. However, in glancing at the article and the references, it appears that a lot of the references in the article, maybe more than half, are also primary sources and will have to come out, along with the text. This may decimate the article, but that's the way it goes. @SandyGeorgia:, do you concur with my actions and assessment, here?

For future reference, if anyone needs to remove content in this article (or any article that needs to be MEDRS-compliant), the template {{uw-medrs}} is available to assist with notifying the authors. You can use {{subst:uw-medrs|Puberty blocker|sourced=yes}} if the user included a source but it isn't MEDRS-compliant; or the default version if they didn't include any source. (Additional parameters available; see the /doc .) Thanks, Mathglot (talk) 03:18, 3 April 2021 (UTC)

I'm not so sure this (PDF) should be counted as a primary source. It's odd in that it is a review, but instead of being published in a journal, it was prepared by the National Institute for Health and Care Excellence [7] in the UK and commissioned by the England NHS. If that is equivalent to a peer-reviewed journal, then it is a MEDRS review. Crossroads ^-talk- 04:35, 3 April 2021 (UTC)

Yes, Jdbrook questioned that on his Talk page, and I told him I may have been too hasty, and invited him to revert, if upon second look it counts as a survey. I may not be back here soon, so whatever you or he thinks is right, is fine with me. Thanks for adding your thoughts. Mathglot (talk) 05:52, 3 April 2021 (UTC)

@Crossroads: Hi, as Mathglot suggested that you and I see if we can converge, here is what I understood of the review. As the NHS is the health authority in the UK, it seemed an NHS commissioned evidence review by the National Institute for Health and Care Excellence was authoritative both because of its origin and because of the organization that did it. I also found some context at [8]. What do you think? Thanks. Jdbrook talk 21:48, 3 April 2021 (UTC)

Hi, Mathglot; thanks for the ping. It's hard to know where to start on an article like this; reading the lead is painful, and prose cleanup as well as sourcing cleanup is needed, and there is uncited text. The history reveals some student editing, and it looks like the article has never been comprehensively cleaned up, although that shouldn't be hard to do, as the article is not that long. I do agree that, before attempting a copyedit, it is important to first evaluate the sourcing. We can't necessarily just pull out text that is poorly sourced, because the text could be accurate albeit unsourced or poorly sourced. So, one place to start is to go through and systematically identify which are primary sources. I usually pull up all the sources, and put |type= Review or |type= Meta-analysis into the citation template for those that are reviews, and then go back to look at the text relative to the citations attached to it. At minimum, you can put a {{primary source-inline}} or {{better source needed}} on the sources you question, which will make it easier for subsequent editors to either remove the text, or upgrade the source, depending on whether the text is likely accurate but just poorly sourced. You mentioned that you "may not be back here soon", so I haven't pitched in to help as it's hard to know where to start, but if the sourcing is cleaned up, I'll be happy to help with the prose. It's painful to see "In addition to their various other medical uses, ... " in the lead! And in the body ... Puberty blockers are sometimes prescribed off label (with the FDA) to young transgender people, ... SandyGeorgia (Talk) 22:14, 3 April 2021 (UTC)

Reference not correctly interpreted

Equivamp The reference to "Rew et al. DOI: 10.1111/camh.12437" does not conclude that suicide risk is reduced by puberty blockers. This is a misunderstanding on a number of levels.

1. In the "Results" section of Rew et al. (also in the abstract) the different outcomes of primary sources passing search criteria are enumerated; this is not to be conflated with the conclusion of the review. (See conclusion).

2. Rew et al. state that one primary source (Turban et al,. 2020) reports on suicidality, The review does not propose their analysis or a consensus supports such a conclusion.

3. This one primary source does not claim there is a lowered "sucide risk". Turban et al. report on suicidality, suicidal thoughts / ideation.

4. The study (Turban et al 2020) further finds that actual suicide attempts increased by more than 200% although the significance is low due to small numbers.

5. This primary source has been strongly contested (E.g. M Biggs, Arch. Sex. Behav. doi: 10.1007/s10508-020-01743-6) and this is also recognized by the journal's ("Pediatrics") publication of comments which question the poor source (convenience survey) used in the paper and a number of questionable methodological issues and, in particular, a critique that prescription of PB as described in the paper is expected to (by papers own and their referenced data) to increase suicide attempts. Turban et al. contested other, but but not this conclusion.

6. Even editing/limiting the reference to not refer to "Rew et al." but to that of the source (Turban et al.) and to "suicidal thoughts" only, this source would not pass the criteria for WP:MEDRS, since it is a primary source (not the conclusion of the review), and b) on account of the numerous contests and lack of consensus.

7. The review does not reach any specific conclusions other than recommendations for more research and the further need for longitudinal studies. Kindly,KoenigHall (talk) 10:55, 5 April 2021 (UTC)

suicide in trans people is mostly caused by societal issues

"The suicide attempt rate among transgender persons ranges from 32% to 50% across the countries. Gender-based victimization, discrimination, bullying, violence, being rejected by the family, friends, and community; harassment by intimate partner, family members, police and public; discrimination and ill treatment at health-care system are the major risk factors that influence the suicidal behavior among transgender persons." (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/ ) (see also: https://www.psychologytoday.com/gb/blog/the-truth-about-exercise-addiction/201612/why-transgender-people-experience-more-mental-health https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30165-1/fulltext https://pubmed.ncbi.nlm.nih.gov/31509158/ )

New secondary study

This looks like a potentially useful secondary study, doesn't it? Newimpartial (talk) 14:56, 5 May 2021 (UTC)

It's not new, being from 2016, and doesn't mention puberty blockers in the abstract, but may in the review itself which I haven't yet read. But it is a good source, of course. Crossroads ^-talk- 06:25, 6 May 2021 (UTC)

New secondary study

Sorry; the section above included a not-new, and controversial (secondary) study. This is the new secondary study I meant to propose for this article. Newimpartial (talk) 19:39, 8 May 2021 (UTC)

No studies on safety

I think the article should mention the safety of puberty blockers and mention risks. (If there are any risks.)

I can’t remember but I do believe there may have been studies on this.CycoMa (talk) 14:18, 23 May 2021 (UTC)

The article already mentions adverse health risks. --Equivamp - talk 14:53, 23 May 2021 (UTC)

Equivamp sorry misread it.CycoMa (talk) 15:03, 23 May 2021 (UTC)

There is this PubMed Review: [9], "GnRHa therapy prevents maturation of primary oocytes and spermatogonia and may preclude gamete maturation, and currently there are no proven methods to preserve fertility in early pubertal transgender adolescents."

This seems like a safety issue (fertility). Perhaps it should be added to the other two that are cited for

Adverse effects on bone mineralization and compromised fertility are potential risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists.

Thanks. Jdbrook talk 00:06, 26 May 2021 (UTC)

Sure, seems fine. --Equivamp - talk 00:14, 26 May 2021 (UTC)

There is no safety issue with regards to fertility. There are numerous cases of people going on to have children after ceasing to use the puberty blocker (see: https://academic.oup.com/jcem/article/84/12/4583/2864749

https://academic.oup.com/jcem/article-abstract/67/2/368/2651998 )

Types of puberty blockers

This article doesn’t mean that there are different types of puberty blockers.

There are sources out there that mention there are different types of puberty blockers.CycoMa (talk) 17:32, 19 September 2021 (UTC)

Proposed addition to risks of puberty blockers

I would like to suggest adding for risks of puberty blockers: Another effect of puberty blockers is to lower male sexual desire by reducing testosterone ref.

And in the citation:here: “Because serum testosterone concentrations below castration level lead to a pronounced decrease of not only paraphilic fantasies and behaviors but also conventional non-paraphilic sexual activity and desire, LHRH agonists should be used in the most severe cases of (paraphilic) sexual offenders only as suggested in current treatment guidelines.” "Although current results from brain imaging studies suggest that LHRH agonists might have an influence not only on sexual drive but also explicitly on the emotional appraisal of paraphilic stimuli, LHRH agonists should be reserved for the most severe (paraphilic) sexual offenders because LHRH agonists frequently lead to a complete decrease of all sexual behaviors, thereby interfering with fundamental human rights." Thanks. Jdbrook talk 03:50, 22 November 2021 (UTC)

I think this would belong at the article on GnRH agonists or another article about the medication in general. That source states, "It should be noted that ADT should be used only in adolescents with completed puberty and growth, and the initiation of ADT requires adolescents to be at least in Tanner stage V and to have completed bone development." This article is specifically about suppressing puberty. Crossroads ^-talk- 05:35, 22 November 2021 (UTC)

Let's not repeat the mistakes we have made earlier. If we include these findings, we do not repeat them in Wikivoice, and we also include the findings of secondary studies that have reached contrasting conclusions. Newimpartial (talk) 13:25, 22 November 2021 (UTC)

Thank you. Suppressing sexual desire appears to me to be relevant to the process of trying to understand one's sense of gender in the context of one's body, which is why I was suggesting this Lupron side effect could be mentioned in the context of its use as a puberty blocker. I do not know of studies which have said that Lupron does not decrease sexual desire for those who would otherwise be producing more testosterone but agree that if they exist, they would be appropriate for inclusion as well. Thanks. Jdbrook talk 13:51, 22 November 2021 (UTC)

You misunderstand me. I am saying that secondary studies that acknowledge this possible effect, but which conclude that this effect is not a reason to avoid the use of puberty blockers, should also be acknowledged as a contrasting view. Newimpartial (talk) 14:12, 22 November 2021 (UTC)

If there is a secondary study discussing how some practitioners wish to value the risk of suppression of sexual desire in their decision making, that seems like it could go wherever the value assessments about the other risks also go? Thanks. Jdbrook talk 03:35, 23 November 2021 (UTC)

Giovanardi source and desistance rates

Some editors have recently decided to join in helping others reverting out the same long-standing material, rather than discuss per WP:BRD.

It was first removed here, by an editor who claimed that the material was not in the source. That was reverted with a quote from the source in the edit summary. Newimpartial joined in and decided to delete it again, saying The source includes both gender dysphoria and gender variance; this article is only discussing gender dysphoria alone. Okay, fair enough. That could have been corrected in-text rather than deleting the statistic entirely, which I did. Sideswipe9th decided to join in helping the others remove it, saying that Gender dysphoria is not a subset of gender variance (irrelevant - that was in my edit summary, not the text, and in the source's terminology, it is), and then made a statement in reference to their own original research about the source. I then added it with a clarifying quote directly of the source explaining the point.

Newimpartial then helped revert again, and their reason (as attached to the second part in the following dummy edit) reads as follows: *My* reason is that this particular factoid, and the passage of the source to which it is sourced, are about Gender Variance (the superset) and not Gender Dysphoria (the subset). But this article is about the use of blockers for gender dysphoria. So *this*passage* from this source is a misleading, out of context statistic that does not belong in this article. I have left in the reference to the same source that does apparently address gender dysphoria and its treatment.

Okay. First off, the topic of this article is puberty blockers, period, not just "puberty blockers for gender dysphoria". It applies to any use of puberty blockers, including any trans-related use. The source is a WP:MEDRS-compliant secondary source specifically about The dilemma of administering hormone blockers in trans children and adolescents. The text in the source making the point appears early, in the second paragraph, as follows: It is now acknowledged, for instance, that children's GD/GV persists after puberty in only 10–30 per cent of all cases; when it does not, the children are referred to as ‘desisters’. Here is how the source describes GD/GV shortly beforehand: Gender-variant children and adolescents compose a heterogeneous group of persons who present an incongruence between their perceived gender identity and the gender to which they were assigned at birth. This incongruence can cause significant distress (gender dysphoria) and may require clinical intervention.

The desistance rate is a central part of the controversy over the use of PBs. I find baffling the claim that it should not be mentioned in this article, or that this source's discussion of it is not relevant to the use of puberty blockers for children with incongruent gender identity. Crossroads ^-talk- 01:53, 16 November 2021 (UTC)

Posted before I saw Crossroads' comment at the top of the section I agree with Goomba1729's first removal, as the status quo version "Also, in around 70–90% of children with GD, it does not persist after puberty" failed verification in the source. Since Crossroads' preferred version doesn't match that original, this isn't a BRD situation—or else, it's likely that Crossroads' version should be considered the bold addition.

I don't have any verifiability concerns about Crossroads' version "Also, in around 70–90% of children who 'present an incongruence between their perceived gender identity and the gender to which they were assigned at birth", it does not persist after puberty.' That said, since puberty blockers aren't prescribed for gender variance, I lean toward agreement with Newimpartial and Sideswipe9th that mention here is inappropriate. Giovanardi associates the two, but also has time and space to contextualize the vocabulary before introducing the statistics. Firefangledfeathers (talk) 01:58, 16 November 2021 (UTC)

(e-c) Crossroads: do you have any sourcing that blockers are used in treating GV that does not fall within a clinical definition of GD? I am not. If there is no such sourcing, then desistance rates among the entire GV population of children are not established to be relevant to the use of puberty blockers to treat GD.

I thought you were familiar with this issue of GD vs. GV, which is one of the main factors influencing the wide range of desistance measures and the surrounding debate - a debate that is relevant at Detransition, but this article is supposed to confine itself to blockers as a treatment modality (and as far as I know, they are only prescribed for GD, according to the sources I've seen). Newimpartial (talk) 02:00, 16 November 2021 (UTC)

The secondary source treats it as relevant. Editors saying it doesn't belong as essentially saying they know better than the MEDRS.

Let's put it in the form of questions. A. Is it the position of the editors who oppose inclusion that desistance rates of GV/GD in children are not relevant to the controversy over the use of puberty blockers? B. Does Giovanardi treat it as highly relevant? C. Why should we go by the opinions of Wikipedia editors rather than Giovanardi's academic article? Crossroads ^-talk- 02:05, 16 November 2021 (UTC)

Oh, and to help with question B, here is more quoting from the source: Thus, many professionals remain critical about the puberty-blocking treatment (e.g.25,41,42). The primary counterarguments are as follows: At Tanner stage 2 or 3, the individual is not sufficiently mature or authentically free to take such a decision.25,41 It is not possible to make a certain diagnosis of GD in adolescence, because in this phase, gender identity is still fluctuating.25,41,42 Moreover, puberty suppression may inhibit a ‘spontaneous formation of a consistent gender identity, which sometimes develops through the “crisis of gender”’ (p. 375).43 Considering the high percentage of desisters, early somatic treatment may be premature and inappropriate.25 (These are 4 out of the 9 counterarguments.) Crossroads ^-talk- 02:19, 16 November 2021 (UTC)

Not every quote from Giovanardi belongs in the article, and we have no way to determine which to include besides "the opinions of Wikipedia editors". Firefangledfeathers (talk) 02:46, 16 November 2021 (UTC)

No, not just opinions, we can see what the source deems to be relevant. This is no random quote. The source in fact names it specifically as part of one of the nine points made describing the controversy, and it seems to lie in the background of others (e.g. why else speak of gender identity as fluctuating?). Have you read the full article? I have and it is not long. This is a main point. Crossroads ^-talk- 02:52, 16 November 2021 (UTC)

Yes, I've read the paper. I don't think most quotes from Giovanardi would be random; it's quite short and to the point. Firefangledfeathers (talk) 03:06, 16 November 2021 (UTC)

Ok, so I do have verifiability concerns. While I agree that the Giovanardi's paper states Also, in around 70–90% of children with GD, it does not persist after puberty albeit it in the inverse form of It is now acknowledged, for instance, that children's GD/GV persists after puberty in only 10–30 per cent of all cases; when it does not, the children are referred to as ‘desisters’, it does so in error. To support the claim, Giovanardi cites a paper by Drescher and Pula, which has two different rates relating to boys and girls. The passage from Drescher and Pula was taken verbatim, minus sources from the WPATH 7 SoC, page 11. In WPATH 7, those claims are supported by a handful of studies, all of which use either the DSM-III or DSM-IV criteria.

More recent research in this area heavily criticises (pdf link) these figures and the follow-on papers these figures are used in as a base as misleading, resulting in a review of the literature that found Methodological, theoretical, ethical, and interpretive concerns regarding [the] four [most frequently-cited] “desistance” studies. That paper additionally has a follow-up in response to the authors in the field who continue to use this outdated research.

At the very least, there is more up to date research that can and should be cited here and I will endeavour to cite some tomorrow as it is currently 3am in my timezone. I would however recommend against citing this paper by Zucker, Singh, and Bradley as it continues to use datasets from children diagnosed under DSM-III and DSM-IV critera, and is not relevant at all due to the substantial changes made in the DSM-V and ICD-11. Sideswipe9th (talk) 03:14, 16 November 2021 (UTC) edited to correct mistake Sideswipe9th (talk) 03:28, 16 November 2021 (UTC)

Quick response without a full reading: Giovanardi does not state the green quote. Firefangledfeathers (talk) 03:17, 16 November 2021 (UTC)

Third paragraph states the inverse of that insofar as it states that only 10-30% will persist. It is now acknowledged, for instance, that children's GD/GV persists after puberty in only 10–30 per cent of all cases; when it does not, the children are referred to as ‘desisters’. Though I may have quoted the wrong thing there in my tiredness. Will check and adjust my original reply if needed. Sideswipe9th (talk) 03:26, 16 November 2021 (UTC)

It's possible and fine for us to have different objections to the proposal and the old language, but to be clear, a large part of my issue is the bundling of GD and GV in that quote. Firefangledfeathers (talk) 03:27, 16 November 2021 (UTC)

I have the same concerns, I'm just approaching it from another angle. The bundling of GD and GV is part of the academic criticism of the circa 80% desistance rate figure. Sideswipe9th (talk) 03:31, 16 November 2021 (UTC)

Regarding your earlier post, a 2021 paper could not possibly have 'resulted in' a 2018 paper. And while you may feel that the 2018 paper by Temple-Newhook et al. and their rebuttal to critics got it right, we shouldn't be editing based on which papers we personally think are correct. When evaluating sources, these responses do also carry weight. We aren't here to determine the "true" desistance rate, but to rather to simply relay what information experts take into account when debating the appropriateness of puberty blockers. Crossroads ^-talk- 05:12, 16 November 2021 (UTC)

Re a 2021 paper could not possibly have 'resulted in' a 2018 paper that would be true, except that the 2021 paper by Zucker is using patient information from the same patient cohort that was subject to criticism in the 2018 paper. Namely transgender youth who attended the Gender Identity Service in Toronto, between the years of 1975 and 2009, filtered for participants assigned male at birth. Zucker previously used the same dataset in a 2008 paper, where it filtered for participants assigned female at birth. In both datasets, the same methodological flaws exist, that the patients attending the clinic were diagnosed under the DSM-III or DSM-IV criteria, and that approximately 40% of the patients in both datasets were subthreshold for the DSM-III/IV criteria. Zucker et al. are making the same mistake in their 2021 paper that they were heavily criticised for in their 2008 paper.

Re the two responses that you've linked to the 2018 paper, I would also point out that the authors of that paper responded to those criticisms. I would also point out that the paper I cited by Newhook et al. is only one of several sources papers criticising misuse of those datasets. This is not the view of the authors of a single paper, this is the view of multiple independent researchers within this field. I would argue, as does Dr AJ Eckert and Jon Brooks the weight is very clearly 'against' Zucker and his continued use of this discredited data.

Based on the heavy criticism, from multiple scholars, across multiple years I would argue that citing this 70-90% desistance rate as fact is not WP:DUE. Moving beyond the datasets, you stated We aren't here to determine the "true" desistance rate, but to rather to simply relay what information experts take into account when debating the appropriateness of puberty blockers. I agree that we aren't here to determine the true desistance rate, however because this rate is obviously and widely accepted as faulty, it is not used by those professionals. As such, we should not include it here. To do so would be to give undue weight to a fringe theory. Sideswipe9th (talk) 20:04, 16 November 2021 (UTC)

The 2021 paper I was talking about was the Florence Ashley one you cited. But anyway.

No, it is not true that this rate is obviously and widely accepted as faulty, even though some researchers reject it - ones who are advocates of the 'gender affirmation/puberty blocker' treatment route (as opposed to a wait-and-see approach), which route leads to an overwhelming majority of the children on it taking PBs to continue on to take hormones. Naturally, they believe that those kids were not likely to have desisted if not 'affirmed'.

Rather, this estimate still carries a great deal of WP:WEIGHT. The current WPATH Standards of Care states, Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children...Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood. More recent reviews on the topic likewise repeat the statistic. This 2020 review states, Indeed, gender incongruence will desist by early adolescence for the majority of them [11, 12]. Several studies have shown that the percentage of “persisters” lies between 10 and 39% [7, 13]. This 2018 review states, Evidence from the 10 available prospective follow-up studies from childhood to adolescence (reviewed in the study by Ristori and Steensma28) indicates that for ~80% of children who meet the criteria for GDC, the GD recedes with puberty. We also have to count the Giovanardi source that we've already been discussing, as well as the clinicians who did not agree with Temple-Newhook et al. There are other sources too.

It is clear that many researchers hold to this figure as the best we have and are not convinced by the claims that it is invalid. You personally may feel otherwise, but we cannot cherry-pick favored sources and say they are the correct ones, or a lens through which all others must be viewed. Crossroads ^-talk- 06:12, 17 November 2021 (UTC)

The WPATH SoC is an interesting one, it's actually part of the citation chain from Giovanardi, with the research by both Zucker and Steensma being the final source of it. The papers by Newhook, Ashley, and others are criticising both the Zucker datasets and the Steensma datasets. I'd also like to point out that the current version (seventh edition) of the WPATH SoC was written in 2012, prior to the papers by Newhook, Ashley, and others. And according to the WPATH website the eighth edition is due at the end of December 2021. It'll be interesting to see if the next edition of the SoC contains this heavily disputed number, or the research by Newhook and others disputing it.

Obviously I'm not saying we should attempt to pre-guess what WPATH will say in their upcoming SoC, however I do like the second suggestion bellow by Equivamp, that given that this number is in dispute and the exact range is not strictly within context of an article about puberty blockers, that we don't need to mention it here. Certainly we don't need to mention the dispute about it here either, and that may be/should be included somewhere in the Detransition article if it is not already. And then we can revisit this in a month or two's time when the WPATH 8 SoC comes out, as it by nature of being a set of recommendations for transgender healthcare will have undertaken a clinical review of the relevant research in this area. Sideswipe9th (talk) 20:30, 17 November 2021 (UTC)

Comment - please note that, as far as I can tell, the claims under discussion, based on the Giovanardi study, first appeared in this edit by jdbrook, who was prolific for a while at both this article and Gender dysphoria and who had a tendency to insert (or, later, to propose to insert) material out of context to support their point of view. See, for example, several examples of such discussions here. So yes, this material has been in the article for several months, but the circumstances under which it was added do not lend me any confidence that it was ever compliant with policy. Frankly, a lot of poor content was being inserted here in March, and it was easy to miss some of it. Newimpartial (talk) 04:00, 16 November 2021 (UTC)

Pinging Jdbrook because they've been mentioned and everyone else has been pinged. For the record, a lot of Jdbrook's insertions were heavily discussed and were good. Crossroads ^-talk- 04:43, 16 November 2021 (UTC)

I'll also ping Equivamp because they were involved in a short discussion higher on this page about the same text. Crossroads ^-talk- 05:00, 16 November 2021 (UTC)

Thanks for the ping. I can take a closer look at this dispute this evening, but my preliminary thoughts are that the statement that the majority of childhood gender dysphoria resolves by adulthood hardly needs to rely on one source. Equivamp - talk 15:46, 16 November 2021 (UTC)

Thank you also for the ping. I second Crossroads, in particular the laying out of the issues above:

Oh, and to help with question B, here is more quoting from the source: "Thus, many professionals remain critical about the puberty-blocking treatment (e.g.25,41,42). The primary counterarguments are as follows: At Tanner stage 2 or 3, the individual is not sufficiently mature or authentically free to take such a decision.25,41 It is not possible to make a certain diagnosis of GD in adolescence, because in this phase, gender identity is still fluctuating.25,41,42 Moreover, puberty suppression may inhibit a ‘spontaneous formation of a consistent gender identity, which sometimes develops through the “crisis of gender”’ (p. 375).43 Considering the high percentage of desisters, early somatic treatment may be premature and inappropriate.25" (These are 4 out of the 9 counterarguments.)

As Crossroads notes, the desistance rates provide support for several of these concerns, concerns which contribute to the "dilemma" presented by puberty blockers. This dilemma is the point of the article.

I also agree with Equivamp. Thanks. Jdbrook talk 17:13, 16 November 2021 (UTC)

The material you added based on Giovanardi was added to this article, in wikivoice. Even if some such claim is eventually deemed in scope to include here, given the debate over desistance rates in the literature there is absolutely no way any such statement should be made in wikivoice (indeed, it never should have been there to begin with). Newimpartial (talk) 17:24, 16 November 2021 (UTC)

I should have said this sooner, but my arguments were never meant to mean that the material must be included in the exact form in which it was removed. Wording can always be tweaked and adjusted, or more contextualized, if needed; my point is that it should not be removed entirely. Crossroads ^-talk- 17:38, 16 November 2021 (UTC)

Returning to this, it appears clear that the desistance rate being a criticism of the use of puberty blockers should be mentioned. I don't see any reason for any specific percentage to be cited, which as already pointed out is far from consensus-based in the literature. There are probably more robust estimates, as well as relevant context that is outside the scope of this article, at Detransition, which can be linked to. With the specific statistic removed, I don't think the methodology of the source's source is of much importance. The objected-to use of the term "gender variance" doesn't seem to hold much weight either, as it's a nebulous term which the source apparently defines to be... essentially, a transgender identity. Equivamp - talk 03:45, 17 November 2021 (UTC)

I agree that Detransition can be mined for relevant material, but the idea that "gender variance" amounts to a nebulous term...essentially, a transgender identity is not supported by the recent, reliable sources, as far as I know, and essentially serves as a backstop for the now-discredited high estimates of desistance by Zucker et al. Edits earlier this year brought those estimates into this article, but neither they nor their antiquated assumptions belong here. It should be possible to find sources that raise questions about possible risks of puberty blockers in relation to still-uncertain childhood gender identities without inserting such dubious content. Newimpartial (talk) 04:26, 17 November 2021 (UTC)

Equivamp stated that that was how the source defined it, which is correct. Crossroads ^-talk- 06:15, 17 November 2021 (UTC)

Crossroads is correct about my meaning. My point about the Detransition article is that any specific statistics are better off there and simply linked to here. What's relevant to this article is that desistance rates are a common argument against the use of puberty blockers for trans children, which it seems the source supports just fine. --Equivamp - talk 10:25, 17 November 2021 (UTC)

I like this suggestion. I don't think we need to cite the statistics here, especially when they are in such heavy dispute. I'd also suggest that, if it's not already in the detransition article, this dispute should be mentioned with the appropriate weight. Sideswipe9th (talk) 20:30, 17 November 2021 (UTC)

Crossroads, my point was that if a source makes a generalization that is not backed up by recent RS, then we should not follow that source in its confusion (much less borrow its logic in wikivoice).

If the point is indeed that desistance rates are a common argument against the use of puberty blockers for trans children, then that is the point that should be made (and appropriately sourced) in this article. That is not at all the point made in Crossroads' edits here, here and here (right up to 3RR): all of these are statements in wikivoice about desistance rates, and none of them make the argument that desistance rates are an argument against puberty blockers for trans children (common or otherwise).

Equivamp: if you have a source for desistance rates are a common argument against the use of puberty blockers for trans children, could you share (or at least point to) it? I haven't seen that "common argument" point made in RS, although it is quite possibly true. Newimpartial (talk) 17:03, 19 November 2021 (UTC)

The source under discussion is the source for it, and the relevant text has already been quoted in this discussion; it starts as The primary counterarguments are as follows. --Equivamp - talk 18:07, 19 November 2021 (UTC)

I don't think a source listing this point among eight other "counterarguments" against the use of blockers establishes it as a common argument, since the actual mention is limited to Considering the high percentage of desisters, early somatic treatment may be premature and inappropriate. I strongly disagree with you that this is support for saying in wikivoice that it is a common argument; in fact, I haven't really seen anything supporting common, even with in-text attribution. Newimpartial (talk) 18:31, 19 November 2021 (UTC)

This is a MEDRS secondary source specifically and entirely about an overview of the difficulties associated with this heterogeneous group of adolescents and [it] discusses arguments for and against the suspension of puberty. Further, it reviews the main follow-up studies conducted in some of the world's largest clinical centres for gender-variant children and adolescents. It goes on to say about puberty blockers, Thus, many professionals remain critical about the puberty-blocking treatment (e.g.25,41,42). The primary counterarguments are as follows... I see no reason aside from WP:IDONTLIKEIT not to note any of these reasons, as these are the primary points of contention per the source.

Regarding the claims of a generalization that is not backed up by recent RS, as I showed above, many recent RS have not been convinced by the claims that the figure of a majority desisting is unreliable. Per NPOV, we are not to take an editorial stance on the matter. And if your concern was about wikivoice, that could have been fixed without removing it entirely.

I am fine with acquiescing to sticking more closely to how it is stated in the 'primary points' in the source and attributing it as needed. Not mentioning it at all is not warranted; the source mentions it twice after all. Crossroads ^-talk- 01:54, 20 November 2021 (UTC)

I read "primary" to mean "common", but I'm okay with using the source's terminology if that's better. --Equivamp - talk 02:25, 20 November 2021 (UTC)

As the desistance rates keep getting brought up, I am seconding Crossroads again in "many recent RS have not been convinced by the claims that the figure of a majority desisting is unreliable." Equivamp said something similar above, too, I believe we three are in agreement. Just to lay out my understanding:

Several secondaries state that the majority desist, e.g., reviews (Ristori/Steensma 2016, Kaltiala-Heino 2018), guidelines (Endocrine Society guidelines 2017, WPATH guidelines).

A few primaries disagree. This does not necessarily mean a topic is heavily debated. Temple Newhook et al 2018 (not a “review of the literature,” but a paper in which “critical review methodology is employed to systematically interpret four frequently-cited studies”) was immediately rebutted by Zucker (2018, who helped write the DSM-V) and Steensma/Cohen-Kettenis (2018, co-authors of the Dutch studies upon which the medical intervention of young people is based, see the Endocrine Society guidelines 2017), i.e., none of them were convinced, then Temple Newhook and collaborators said they did not agree with the rebuttals (paper referenced above). The other referenced paper, by Ashley (2021), is likely too recent for a rebuttal; it says the desistance rates are irrelevant, again, this is a claim from a primary. So there are a few primaries disagreeing with each other and with the established earlier research.

The recent Singh, Bradley, Zucker paper (2021), written after the Temple-Newhook et al criticisms, reflects responses to the criticisms (e.g.,it separates out subclinical populations). It has not been, to my knowledge, discredited. As the DSM-V came out only in 2013, it is perhaps not surprising that there are not numerous studies following up children diagnosed after that time who have been followed through the end of puberty. Especially as the affirmative model with its often rapid medical intervention came in use (Hidalgo et al, 2013) soon afterwards. The studies before 2013 merely refer to desistance with the earlier DSM's, the ones which existed at the time.

One editor noted that the new WPATH guidelines are coming out soon, however, the previous ones (soc 7) did not do well in a recent systematic review and quality assessment of guidelines. I do not know the Wikipedia protocol when secondaries (either guidelines or reviews) are found to be lacking in this way. Thanks. Jdbrook talk 02:43, 21 November 2021 (UTC)

The claim above that the majority desist - and the sources for it - beg the question "the majority of who desist"? Statistics from sources where the denominator is unclear, or where it is in fact clear but it clearly doesn't apply to the prescription of puberty blockers, can't really be taken as relevant to this article. (The same sources may be relevant for other statements they make about blockers, but this this article isn't Vague, misleading and irrelevant statistical claims regarding puberty blockers - nor should it be allowed to be come that article due to editorial inattention.) Newimpartial (talk) 02:53, 21 November 2021 (UTC)

Do you know better than the experts who wrote the numerous reviews just cited? This exact argument - that researchers have to just throw out all the existing statistics on desistance because of diagnostic criteria tweaks (supposedly most of these kids so distressed they were brought to a clinic and diagnosed with the same diagnosis then given to adult medical transitioners can just be waved off) - is the one we've shown to be rejected by many researchers. We on Wikipedia are supposed to go by the expert reviews; we don't act like we can pick and choose which experts to represent based on who we feel to be correct, 'statistically' or otherwise.

Jdbrook, any suggestions for new text representing the major points from the Giovanardi source? Crossroads ^-talk- 06:37, 21 November 2021 (UTC)

Crossroads: most of these kids so distressed they were brought to a clinic and diagnosed with the same diagnosis then given to adult medical transitioners - do you have evidence this was so? Zucker saying so isn't really evidence, under these circumstances, and people quoting Zucker and colleagues as saying so also isn't evidence. And no, that skepticism isn't just my opinion as an editor; it is the official stance of the community of practice in Canada and the vast majority of Canada's researchers and experts. Newimpartial (talk) 12:59, 21 November 2021 (UTC)

Desist from what: the diagnosis of gender dysphoria at the time (or its corresponding diagnosis/name at the time).

From the secondary review Ristori & Steensma 2016:

Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender.

[...]The conclusion from these studies is that childhood GD is strongly associated with a lesbian, gay, or bisexual outcome and that for the majority of the children (85.2%; 270 out of 317) the gender dysphoric feelings remitted around or after puberty (see Table 1). However, there may be a number of arguments to nuance this high percentage of desistence.[...] Based on this information, it seems reasonable to conclude that the persistence of GD may well be higher than 15%. However, desistence of GD still seems to be the case in the majority of children with GD.

The more recent article by Singh, Bradley, Zucker (2021) splits up study participants in detail:

In our study, we did not find that persistence was more common among boys who were threshold for the diagnosis of GID when compared to the boys who were subthreshold (13.6% vs. 9.8%) although the pattern was in the same direction as that found by Wallien and Cohen-Kettenis (52) and Steensma et al. (51)

Specifically about their methods, there is more in the paper: In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters.[...] Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters.

Someone assessed at age 8 in 2013 with the DSM-V would not have yet reached age 20 in 2021, so this study cannot yet be repeated, as far as age of initial assessment and time followed, with an initial diagnosis based upon DSM-V.

Thanks. Jdbrook talk 14:31, 21 November 2021 (UTC)

And how often are puberty blockers prescribed for those assessed (whether clinically or not) at 7 or 8 years of age? There is a reason Zucker's research is largely discredited and now ignored in Canada, where it was initially conducted. Newimpartial (talk) 15:44, 21 November 2021 (UTC)

I've been re-reading this entire discussion, and there was a question that @Crossroads: asked a few days ago Is it the position of the editors who oppose inclusion that desistance rates of GV/GD in children are not relevant to the controversy over the use of puberty blockers? that I want to pick up on and I think has been misapplied in this attempt to cite Giovanardi in this article. The question implies that the position of Giovanardi, that puberty blockers in trans youth are controversial because of desistance rates, is one shared by the relevant international guidelines. However this is not the case.

We've discussed WPATH SoC 7 above, and I've already stated that WPATH SoC 8 is due at the end of this year. However WPATH isn't the only internationally relevant guidance in this area, and there are newer guidance notes than WPATH 7. Here's what each of them have to say.

UCSF, Guidelines for the Parimary and Gender-Affirming Care of Transgender and Gender Nonbinary People, June 2016 While there still exists uncertainty as to which GNC children will continue into adolescence and adulthood with transgender identities and/or gender dysphoria and which will not, it is been noted in prior studies that increased intensity of gender dysphoria is a predictor of a future transgender identity. This finding is subject to confounding, as youth who repress gender dysphoria due to safety or lack of basic language to express ones feelings may be no less likely to persist into adulthood, yet not present at an early age. Clinical experience has shown that it is those children who are the most dysphoric who seek social transition Page 188.

American Academy of Pediatrics, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, October 2018 This developmental approach to gender affirmation is in contrast to the outdated approach in which a child’s gender-diverse assertions are held as “possibly true” until an arbitrary age (often after pubertal onset) when they can be considered valid, an approach that authors of the literature have termed “watchful waiting.” This outdated approach does not serve the child because critical support is withheld. Watchful waiting is based on binary notions of gender in which gender diversity and fluidity is pathologized; in watchful waiting, it is also assumed that notions of gender identity become fixed at a certain age. The approach is also influenced by a group of early studies with validity concerns, methodologic flaws, and limited follow-up on children who identified as TGD and, by adolescence, did not seek further treatment (“desisters”).45,47 More robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family. Section "Developmental Considerations"

American College of Osteopathic Pediatricians & American Academy of Pediatrics & Human Rights Campaign Foundation, Supporting and Caring for Transgender Children, September 2016 However, delayed-transition advocates cite these studies to suggest that clinicians cannot distinguish between so-called “persisters” (children who will become transgender adults) and “desisters” (children who become comfortable with their originally assigned gender over time). There are serious problems with this claim. The first is that the percentage of children with ongoing gender dysphoria is probably higher than reported. In some cases, researchers’ assumptions artificially inflate the proportion of desisters. One widely cited study, using data on 127 Dutch youth, counted participants as desisters if they did not actively return to the clinic as teenagers. Pg 13-16. Note that the Dutch study is one of the four that Newhook et al. criticised in their later 2018 paper. There's also a lot more here that I think could be relevant but would make this long reply significantly longer.

Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents, June 2018. Does not contain any reference at all to desistence rates. As such I think it is acceptable to say that in Australia desistance rates is not a factor when considering puberty blockers for trans and non-binary youth.

I cannot cite guidance from the UK as it is underdeveloped, there are no NICE treatment pathways for trans and non-binary youth, and the procedures that GIDS at Tavistock use are currently subject to a review.

In summary of the above. UCSF note the uncertainty, but it does not factor into their considerations because of issues in the research. AAP do the same. ACOP same but justify that over two pages. Australia do not mention desistence rates at all in their guidance. UK guidance is subject to review and otherwise underdeveloped and non-existent.

Also one thing I want to pick up on that Newimpartial stated. There is a reason Zucker's research is largely discredited and now ignored in Canada, where it was initially conducted. The only source from the above that cites Zucker is the ACOP/AAP/HRCF paper, and does so to criticise the statistics relating from his work. Sideswipe9th (talk) 17:49, 21 November 2021 (UTC)

The ACOP source appears to be another one supporting my suggestion: However, delayed-transition advocates cite these studies to suggest that clinicians cannot distinguish between so-called “persisters” (children who will become transgender adults) and “desisters” (children who become comfortable with their originally assigned gender over time). --Equivamp - talk 17:58, 21 November 2021 (UTC)

@Equivamp: if we did phrase it the way you suggested previously, for balance sake we should also point out that desistance rates are not considered clinically relevant by the above bodies as well, either in sentence or elsewhere in the article. I think it needs to be made clear that the arguments against use of puberty blockers for trans and non-binary youth are sociological and not medical. And that medically speaking they are non-controversial. Sideswipe9th (talk) 18:04, 21 November 2021 (UTC)

Of course the arguments against the use of puberty blockers should not just be mentioned and moved on from; all of what RS have to say about them should be covered, including criticism of them and how the arguments are viewed by the experts. But, like Crossroads points out below, that the arguments are "not medical" is not borne out by the RS. Also, it may not be so simple to categorize things into one or the other - the recent UK rulings on their use hinged on the age at which informed consent could be given, I recall. Would that be purely a medical criticism? --Equivamp - talk 20:48, 21 November 2021 (UTC)

"Sociological and not medical" is contradicted by the ACOP quote pointed to by Equivamp, the Giovanardi review, the other reviews pointed to by Jdbrook, WPATH SOC 7 (which is still current; WP:CRYSTAL applies), and the fact that a major Swedish hospital has discontinued use of PBs outside of research studies. The Royal Australian and New Zealand College of Psychiatrists states in 2021, However, evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate. This is a debate among medical experts; affirmation activists' proclamations of victory are premature.

The UCSF document does not seem to contradict this and even notes "uncertainty"; between that and the 2018 Australian document, absence of mention is not evidence of a position against concern about desistance. As for the Human Rights Campaign document, they are an activist group, and how much of the orgs. whose names are on that document support that claim is debatable. I note that one of the contributors to it is Diane Ehrensaft, about whom this 2018 KQED article interestingly notes, Diane Ehrensaft, the San Francisco Center’s mental health director and a leading proponent of early social transitioning, acknowledges this approach has been controversial. “There are some people that think folks like myself, and the people at our clinic, have fallen off the deep end,” she told me. She wasn’t just talking about the religious right, either. She was referring to other mental health professionals. Likely, the other contributors to the HRC document are of the same faction; in any case, this is not an impartial review of the state of the debate.

I don't know why Newimpartial keeps bringing up Zucker; he is far from alone in his views on this matter, and he is not being cited as a main authority. Unsourced assertions about Canada are also not relevant, and besides, this isn't Mapleleafpedia. We take the view of experts worldwide. Crossroads ^-talk- 20:00, 21 November 2021 (UTC)

A review article, that broadly bears out the mainstream Canadian view of gender-affirming care for trans youth, is here. The provincial standards of care are pretty easy to find, and I note that the revised protocols in the Yukon seem the most up-to-date at the moment. Would that this were Mapleleafpedia, but dismissing current Canadian souces in favor of scholarship and guides from other, cherrypicked organizations isn't the way Wikipedia is supposed to work anyway. Editors can't insert a view in wikivoice (as jdbrook has often done in the past) if the division of professional opinion is fairly balanced - even if part of that balance is Canadian. And the reason I keep bringing up Zucker that the recently removed, UNDUE passage from this article was sourced to a single secondary study parroting Zucker without mentioning the recognized criticisms of his work. That doesn't represent the consensus of current scholarship. Newimpartial (talk) 20:35, 21 November 2021 (UTC)

@Crossroads: I'm still reading the other replies but wanted to address something related to one point you've raised. I would treat anything SEGM state as suspect, or at the very least heavily biased and non-impartial. Sideswipe9th (talk) 21:31, 21 November 2021 (UTC)

@Crossroads: issues with SEGM aside, I would cite WP:SOURCEGOODFAITH at you, as your argument appears to be that because of a single contributor that you have singled out from all of the others the entire source is suspect.

As for RANZCP, if you look at the single inline citation for that quotation, it cites WPATH SoC 7, which other sources have diverged from or called into question about this point.

As for why Zucker's name keeps coming up, while I don't want to answer for Newimpartial I would state that it is because of the datasets. Desistance research is based almost exclusively on two patient cohorts, one from Zucker's former clinic in Canada, and the other from Steensma's clinic in The Netherlands. All of the research that you have cited thus far, including the remarks of Giovanardi is based upon Zucker's and Steensma's data.

@Equivamp: the recent UK rulings on their use hinged on the age at which informed consent could be given, I recall. you're referring here to the original judgement of Bell v Tavistock. I would direct your attention to the appeal judgement paragraph 89, wherein the judge stated We conclude that it was inappropriate for the Divisional Court to give the guidance concerning when a court application will be appropriate and to reach general age-related conclusions about the likelihood or probability of different cohorts of children being capable of giving consent. I'd recommend reading the full appeal judgement if you haven't already, as it highlights significantly the issues caused by the lower court ruling on something they should not have. Sideswipe9th (talk) 22:11, 21 November 2021 (UTC)

I never claimed SEGM to be neutral either; I was using them as a convenience link.

Newimpartial, this Canadian review you linked in large part actually supports what I've been saying. How common is gender dysphoria among youth, and does it persist?...Not all children and youth who report gender identities different from their gender assigned at birth will experience persistent gender dysphoria. Retrospective studies suggest gender dysphoria persists from childhood into adulthood in the range of 12%–27%.12 Prevalence studies regarding persistence are controversial, with many critics suggesting that previously reported prevalences were erroneous for a variety of reasons: loss of follow-up participants and possible misclassification as not transgender, changing criteria of gender dysphoria, and reasons for referral to specialists (e.g., youth may have been referred for not conforming to their cultural gender norms, rather than because they experienced gender dysphoria).24 The trajectory of gender dysphoria in children is different from that of gender dysphoria presenting in adolescence.... So yes, even this notes these desistance rates, just like Giovanardi does. Also noting the criticisms of those rates does not negate this - and doesn't side with one over the other.

And no, your claim that Giovanardi is just 'parroting Zucker' is not accurate. You are reducing a large body of research by many people to one man. Secondary sources are not disregarded based on editors' own claims that the sources are wrong. Crossroads ^-talk- 22:00, 21 November 2021 (UTC)

Crossroads, please don't shift goalposts. The question for this article is not how often does gender dysphoria persist from childhood - for which the consensus is essentially, existing data don't allow a convincing answer to this question, but rather, as pointed out earlier by Sideswipe9th, are desistance rates considered clinically relevant to recommendations on the use of puberty blockers. If I am reading correctly the review article I linked above, these Canadian researchers do not consider them clinically relevant, which is the point at issue here.

As far as Zucker's findings are concerned, I have literally just linked to one of many, many secondary sources and review articles pointing to the methodological problems with his work. You and jdbrook do not get to cherry-pick one study that cites those results without noting the methodological issues and conclude, "See! We can include these findings in wikivoice without noting any objections to them because one carefully chosen MEDRS study says so, even if much of the rest of the literature does not". And that isn't a straw man, either, because that is literally the text that jdbrooks introduced and you edit, warred to retain.Newimpartial (talk) 22:10, 21 November 2021 (UTC)

I agree with Newimpartial. We aren't here to solve a problem that is in dispute amongst researcher. The question here is whether or not that dispute is clinically relevant. And the Canadian guidance states at the end of that section For such reasons, it is often the goal of professionals and parents to determine for which adolescents gender dysphoria is more likely to persist into adulthood. However, a recent Canadian commentary by medical and mental health professionals cautions that such a preoccupation was a barrier for children and adolescents with gender dysphoria in accessing proper medical and mental health care. The implication from that is that it is not considered clinically relevant and that considering it clinically relevant can lead to patient harm through barriers to treatment. The AAP concurs with this stating More robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family. as does ACOP In light of these facts, it is clear that many children who are gender-expansive or have mild gender dysphoria do not grow up to be transgender — but these are not the children for whom competent clinicians recommend gender transition. emphasis theirs. Sideswipe9th (talk) 22:23, 21 November 2021 (UTC)

"The question here is whether or not that dispute is clinically relevant" - not really. We are not a clinical guide. 'Whether or not that is clinically relevant' is itself the subject of dispute among experts, per the secondary sources and experts quoted above. What we do is relay what the secondary sources say. Crossroads ^-talk- 22:31, 21 November 2021 (UTC)

If 'Whether or not that is clinically relevant' is itself the subject of dispute among experts, per the secondary sources and experts then that is what this article should reflect, rather than including disputed statistics without explanation - which has been the approach you have defended to date. I await language from someone characterizing this dispute in a way that reflects BALANCE and DUE. Your marshalling a list of resources that happen to take one side of this debate doesn't help in a way that I can see, but I suppose what matters is the result. Newimpartial (talk) 23:13, 21 November 2021 (UTC)

You must have missed what I said above: "I am fine with acquiescing to sticking more closely to how it is stated in the 'primary points' in the source and attributing it as needed." As for some of the other replies above, I reiterate that it is not the place of Wikipedia editors to interpret secondary sources as right or wrong through the lens of their own conclusions about the primary sources. We report the secondary sources, using due weight in cases where some contradict others. It really doesn't need to be this hard. Crossroads ^-talk- 05:43, 22 November 2021 (UTC)

WEIGHT would not allow this article to report any of Giovanardi's "primary points" in Wikivoice - or to report the parroted statistics at all - without clearly reporting that their conclusions and analysis are disputed by other (in this case, more recent) sources. My insisting on this is not interpreting secondary sources as right or wrong through the lens of their own conclusions about the primary source- it is my evaluating the primary source, and comparing how different secondary sources use it based on what the various secondary sources have said about the findings of the primary (and the debate among secondaries). And as long as I don't try (as you or jdbrook have) to insert my own opinions into the article using selective quotation or paraphrase, I can have as strong an opinion on the actual primary and secondary studies as I want to have.

Also, to be (perhaps painfully) clear, when I said above The question for this article ... is whether resistance rates are clinically relevant, what I meant was, to decide whether and how to discuss desistance rates in this article, editors must assess the BALANCE of what recent RS have to say about whether these rates are clinically relevant. If the consensus of sources is that they are relevant, then this should be mentioned in the article. If the consensus is that they are not relevant, then the article should probably not mention the issue. And if the sources are in disagreement, then the article could include "both sides" with appropriate attribution, if we can reach some kind of consensus on language to use. So far, I have seen no proposals on this from Crossroads or Equivamp, and jdbrook seems to simply want his wikivoice statistics reinstated in the article, having apparently learned nothing from the discussion so far. Newimpartial (talk) 13:14, 22 November 2021 (UTC)

I'm aware of the subsequent events in the case, Sideswipe9th, but they aren't germane to my point. --Equivamp - talk 22:52, 21 November 2021 (UTC)

I thought that the question under discussion was whether to mention the desistance rates, found in many secondary sources, on this page, and I second Crossroads' finding that they are key (in particular the fact that they are high, the majority in every study) to the point of Giovanardi. That another secondary states, regarding the rates:

For such reasons, it is often the goal of professionals and parents to determine for which adolescents gender dysphoria is more likely to persist into adulthood. However, a recent Canadian commentary by medical and mental health professionals cautions that such a preoccupation was a barrier for children and adolescents with gender dysphoria in accessing proper medical and mental health care.24However, a recent Canadian commentary by medical and mental health professionals cautions that such a preoccupation was a barrier for children and adolescents with gender dysphoria in accessing proper medical and mental health care.24

reads to me as saying Temple Newhook does not like the consequences of taking the rates into consideration. That doesn't make the rates irrelevant or wrong, more generally. It is pointing out that being concerned with possible desistance can have an effect on treating young people with gender dysphoria (which Temple Newhook does not like). Giovanardi is also saying this concern is an issue for treating young people with gender dysphoria. I continue to agree with Crossroads and Equivamp I believe. Thanks. Jdbrook talk 03:43, 22 November 2021 (UTC)

So you agree with them that the statistics you inserted into the article should not be included in wikivoice, and that the point that could be included from Giovanardi is not the (disputed) statistics themselves, but the point that desistance among gender dysphoric children is used as an argument to restrict the use of blockers? Because that is what I understand them to be saying. I have not seen a recent proposal from either Equivamp or Crossroads to actually include the disputed rates, of questionable relevance, in this article. Newimpartial (talk) 13:14, 22 November 2021 (UTC)

To clarify, what is the current proposed phrasing? Thanks. Jdbrook talk 13:54, 22 November 2021 (UTC)

I hadn't made any proposals yet in large part because my last few comments on this talk page were under the impression that you, Newimpartial, either did not agree with or did not understand what I'd argued for including. This comment of yours proves that understanding is not the issue - but is it an agreement issue? I'm not really sure how else to read it when you object to calling an argument common when the/a source describes it as primary. --Equivamp - talk 01:07, 23 November 2021 (UTC)

To me there is a non-semantic difference between the two: if a source refers to an argument as primary it is lending its own weight to that argument, but is not making a claim about support for that argument by others (unless it says so in some other terms). But if a source refers to an argument as common, it is saying that the argument is supported by multiple other sources. So I so not see those two terms as equivalent. Newimpartial (talk) 03:07, 23 November 2021 (UTC)

Given the extent to which the specific figures are disputed and discredited in other literature, as discussed at length above, quoting them here (without that context) seems like it'd be giving them wp:undue weight. That could be resolved by contextualizing them with the other sources about the issues with them; whether it's better to do that here or leave both the figures and the issues with them to the Detransition article, I'm not sure. It does seem like, if "after puberty many people aren't trans" is a common argument against blockers, then inclusion some of the information about how accurate or inaccurate or disputed that statement is for various different populations could be relevant. -sche (talk) 02:09, 23 November 2021 (UTC)

I just posted this. A mere 110 bytes of what such clinicians' argument is about this, attributed, and leaving the back and forth about exact rates for another article to deal with. Crossroads ^-talk- 07:36, 23 November 2021 (UTC)

Yeah this wording is OK with me. Makes it fairly clear that the statistics are in dispute while still recognising that opponents to the use of these drugs in this manner use them, and avoids the need to actually cite the disputed number. Sideswipe9th (talk) 16:03, 23 November 2021 (UTC)

"Off-label" use

@-sche: re this edit. I believe that when originally added, it was supported by this source, however, on reviewing it, this does not seem to be a very strong source for the statement. (This would certainly be a better source, and may be otherwise useful to this article.) Not to speak for the other editor, but I think that "with the FDA" was intended to mean that other drug agencies do have suppressing puberty in trans youth as an approved use of these drugs. If that's the case, if it's re-added, it should be presented differently than it was originally to avoid US-centrism. (And not to mention in a way that isn't implying that off-label use is somehow uncommon or negative.) --Equivamp - talk 02:06, 23 November 2021 (UTC)

In the US, having something on label with the FDA means: "It is important to know that before a drug can be approved, a company must submit clinical data and other information to FDA for review. The company must show that the drug is safe and effective for its intended uses. “Safe” does not mean that the drug has no side effects. Instead, it means the FDA has determined the benefits of using the drug for a particular use outweigh the potential risks." (From the FDA web site)

In the UK, the wording for approval seems different: "Apart from Sustanon®, there are no licensed products with an approved indication for the treatment of gender dysphoria." Sustanon seems to be a testosterone replacement. There is a list of European medicine authorizing agencies here. Maybe someone will figure out how to search it better than me. Thanks. Jdbrook talk 03:51, 23 November 2021 (UTC)

I'd support adding something about this with good sources. Crossroads ^-talk- 07:38, 23 November 2021 (UTC)

@-sche: @Equivamp: are there sources/countries where these drugs have been approved or are "on-label" for treating gender dysphoria, it was raised as a possibility above? I do not know of anything beyond the above two cases, where, as far as I've been able to find, they aren't on-label (USA) or approved (UK). Thanks. Jdbrook talk 20:22, 23 November 2021 (UTC)

Not exactly my wheelhouse, but none that I know of. I doubt that there are, because my understanding is that off-label prescriptions are even more common in pediatric medicine than for adults. --Equivamp - talk 01:11, 24 November 2021 (UTC)

@Equivamp: Puberty blockers are on label for precocious puberty which only affects young children, and which is much rarer (2% of high school students identify as transgender right now, i.e. ~1/50, while precocious puberty affects 1/5,000 to 1/10,000).

Studies of puberty blockers for gender dysphoria have not shown puberty blockers are safe and effective for treating gender dysphoria. The NHS/NICE evidence review found that evidence for puberty blockers helping gender dysphoria was very low certainty, and the UK central gender clinic did not find benefit in their most recent study (but did see that most people they put on puberty blockers went on to hormones). The Endocrine Society evidence review similarly found that evidence was only low quality GRADE for the use of puberty blockers. (Their recommendations are based on the Dutch studies which only admitted into treatment those who had lifelong extreme gender dysphoria and were psychologically stable, so not relevant for the large number of young people with gender dysphoria nowadays who have comorbidities.)

I am aware that at least the US has some grnh agonists approved for precocious puberty, and you and I have discussed the GRADE rating specifically for this article, I think. What is the point of this line of discussion? --Equivamp - talk 12:52, 24 November 2021 (UTC)

@Equivamp: I might have misunderstood, it is often implied that puberty blockers are used off label for gender dysphoria because they are being used for children. I thought you were alluding to that. I was pointing out that the on-label use for puberty blockers is also for children, that is, that these drugs in particular have been tested for on-label use for children, for a different, much rarer, condition. And that many studies have been done for their use for treating gender dysphoria, but these studies have not established that puberty blockers are safe and effective (in some cases showing that they don't seem to do much, however, puberty blockers are correlated with an apparently much higher prevalence of going on to hormones, which is doing a lot if it is causal). Thanks. Jdbrook talk 14:09, 24 November 2021 (UTC)

I was only referring to puberty blockers in the sense of this article. I don't think SYNTH about the reasons for it being off-label belongs in the article. --Equivamp - talk 18:14, 24 November 2021 (UTC)

@Equivamp: Thank you. I thought you were asking, above, if they were "on-label" anywhere else. I am not aware of them being approved anywhere else for gender dysphoria. I am under the impression that "off-label" refers to the US approval system specifically. So the statement is that puberty blockers are off-label for the treatment of gender dysphoria. It doesn't require SYNTH, I was just trying to address your concern that they were on-label (or approved) elsewhere. I have no evidence of this. Thank you. Jdbrook talk 06:00, 25 November 2021 (UTC)

Secondary misquotes primary result in abstract, quotes it correctly in body

Hi all, I am not sure what the Wikipedia policy is on the following. Currently the page says puberty blockers:

...can improve psychological well-being in these individuals,[10][11][12] including a reduction in suicidality.[8]

The abstract of the article [8] by Rew et al (2021) does indeed say:

Positive outcomes were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.

However, when you read beyond the abstract, the body of the review actually says:

The most recent study by Turban et al. (2020) was the first to demonstrate that access to pubertal suppression during adolescence was associated with decreased lifetime suicidality among transgender adults.

The distinction between association (correlation) and outcomes (causation) is important, if you go back to the actual Turban paper, in fact, it states:

Limitations include the study’s cross-sectional design, which does not allow for determination of causation.

That is, the paper they are quoting explicitly says that it cannot show cause and effect (i.e., that giving puberty blockers reduces lifetime suicidality). Causation could in fact even be the other way (i.e., if you were more likely to have lifetime suicidality, perhaps due to observed comorbidities, you might have been less likely to be given puberty blockers).

Would it be more accurate to say:

and an association has been found between puberty blockers and decreased lifetime suicidality ?

Thanks. Jdbrook talk 11:06, 24 November 2021 (UTC)

Absolutely, and I have made this change. Thanks for catching that. WP:MEDRS specifically notes this problem, stating at WP:NOABSTRACT, Don't just cite the abstract...the abstract necessarily presents a stripped-down version of the conclusions and omits the background that can be crucial for understanding exactly what the source says, and may not represent the article's actual conclusions. This is a perfect example of that. Crossroads ^-talk- 06:08, 25 November 2021 (UTC)

Thank you very much. Jdbrook talk 06:15, 27 November 2021 (UTC)

WPATH 8 SoC Draft

Earlier in the discussion on Giovanardi, I mentioned that the 8th version of the WPATH SoC was due at the end of this year. It seems that WPATH have released the draft version of it, as part of the final consultation/review process. While I know we can't cite it yet and accessing it is a bit of a pain as you have to do it through several survey links, one for each chapter, it might be good to at least review it so that when the final version does drop we have at least some idea of what it's going to say. Of particular interest for here would be the chapters on adolescent, child, and hormone therapy. I'll hopefully be starting into it myself over the weekend, and I'll maybe have some early thoughts on that as I read it. It almost certainly will be of interest to other articles on Wiki as well. Sideswipe9th (talk) 21:09, 2 December 2021 (UTC)

When comparing the v7 and draft v8 WPATH SoC, there are substantial changes. In length alone, previously the single chapter on child and adolescent assessment and treatment was 11 pages. In the draft v8 SoC, these have been split into two separate chapters for child and adolescent. Including citations, the child chapter is 24 pages, and the adolescent chapter is 46.

With respect to the content for this article, the adolescent chapter seems the most relevant. The child chapter covers the period up the start of puberty, and has no recommendations for pharmaceutical intervention. Instead it covers recommendations for psychosocial supports, training for Health Care Professionals, and recommendations for assessments used by HCPs.

Within the adolescent chapter, language has changed significantly. The only place where the word "desist", "desistence", or other variants is used are in citation titles. Instead a positive form is used, "persist", "persistence", etc. "Continuity" and "discontinuity" is also used where "desistence" would have previously been.

Using the language used previously in this talk page for convenience of editors here, where the chapter does mention desistence vs persistence, it does so while pointing out that the research in this area is complicated and hard to interpret. The research papers I raised previously by Temple Newhook, as well as its follow-up response by Winters are directly cited on page 22 of the draft, in the context of the methodological issues of the studies discussed within those papers and are given substantial weight by WPATH. Where it does mention desistence, it characterises it as a subset instead of a majority, citing de Vries, Ristori & Steensma, Singh, and Wagner. The 2018 paper by Kaltiala-Heino, previously mentioned above by Crossroads is also mentioned however it is done so only in the context of how there is lack of research for gender diverse youth identifying in later adolescence versus those who identify in early adolescence/childhood.

It is also quite specific in how it characterises the dataset from the Amsterdam clinic, as being "unselected" citing this 2019 paper by Arnoldussen and the 2011 paper by de Vries linked above. Arnoldussen states that despite an increase in patient numbers between 2000 and 2016, the percentage of diagnosed adolescents remained consistent (mean 84.6%), as did the percentage starting puberty blockers and/or hormones (mean 77.7%).

In light of this, the chapter makes no reference at all to a specific desistence rate as we have done previously here, but it does give a recommendation that medical or surgical interventions for adolescents should only be recommended when a patient has evidence of persistent gender incongruence or nonconformity over a period of several years.

Some other interesting bits from the draft adolescent chapter relevant to this article:

• WPATH are recommending using ICD-11 only for diagnostic criteria.
• That puberty blockers are prescribed at Tanner stage 2, and that treatment progresses to hormone treatment by age 14 unless contraindicated.
• That for AFAB adolescents who are experiencing gender incongruence, but either don't desire or are not ready to proceed with other treatments, menstrual suppression agents should be considered/recommended. While GnRH analogues could be used for this, the chapter instead recommends other options including oestrogen-progestin contraceptives, progestin-only formulations for transmasculine/non-binary adolescents, or IUD implants. The exact recommendation being patient circumstance specific.

As I said before, given that this is still a draft, I don't think we can cite it yet. However I think we can responsibly use this draft to hash out rough changes that we may want to implement here. At the very least, I'd suggest we may want to insert a sentence into the final paragraph of the Legal and political challenges subsection, in light of WPATH stating that the research in this area is complicated and difficult to interpret. We may also want to add a paragraph to Medical organization policy changes, as this substantial change from WPATH seems like it would fit there.

As I don't know which of you have this page on your watchlists, I'm pinging @Crossroads, Newimpartial, Firefangledfeathers, Jdbrook, Equivamp, and -sche: as you all contributed to the discussion previously on Giovanardi. Note that again, while the draft chapters are on the WPATH website, in order to access the draft adolescent chapter, you need to do so via the survey links in this statement by WPATH.Sideswipe9th (talk) 22:39, 6 December 2021 (UTC)

Do they provide any kind of definition for what is considered an 'adolescent' vs a 'child'...? The only reason I bring this up, one of the bullet points you mentioned above kind of jumped out at me as somewhat of a red flag, in that their use of 'adolescent' might be drastically different from the average person's. Puberty blockers are prescribed at Tanner Stage 2... According to our article on Tanner levels"), that would be age 9 for boys and 10 for girls (even though puberty onset is typically at a younger age in girls, Tanner is based squarely on outwardly observable physical traits, and and the relevant anatomy just happens to be more visible with boys). Anyway, if WPATH is using "adolescent" in reference to 9- and 10-year old boys and girls, that wouldn't be something that should be overlooked or glossed over, as adolescent typically means, to most people, teens to early 20s (or beginning at age 12 is another common definitiοn). 2600:1702:4960:1DE0:38CD:5C90:85F:5464 (talk) 02:02, 8 December 2021 (UTC)

I'll need to recheck, but from memory in the context of the draft chapters, the child chapter deals with up to the start of puberty. Adolescent is from the start of puberty until 18. No specific ages are mentioned beyond the transition from adolescent to adult services at 18, I believe that's in part because when a person starts puberty is individualistic. But I'll re-read those chapters again tomorrow to confirm. Sideswipe9th (talk) 02:52, 8 December 2021 (UTC)

That said, at least within medical literature adolescence starting at around age 10 is not out of the ordinary. Likewise for UNICEF. Sideswipe9th (talk) 03:10, 8 December 2021 (UTC)

Gender dysphoria

Please note that edits relating to the literature on children and gender dysphoria are now being made to Gender dysphoria. The resources presented on this Talk page seem relevant to the treatment of those issues, and I have no intention of porting all of it over myself. Newimpartial (talk) 15:57, 10 December 2021 (UTC)

Also a related set of edits has started at Sex assignment. Newimpartial (talk) 16:21, 11 December 2021 (UTC)

Also see the dubious stub at Gender identity movement. Newimpartial (talk) 19:52, 11 December 2021 (UTC)

Just so I can assist in porting over notes, are there any you have in mind that are relevant? I'm not sure what the notes from here could contribute at Sex assignment, but certainly there's some recent stuff from the WPATH 8 SoC draft that would be relevant at Gender dysphoria. Sideswipe9th (talk) 16:53, 11 December 2021 (UTC)

Fully reversible

The article states baldly that the effects of puberty blockers are "fully reversible", but this gives a misleading impression of certainty here. The statement should be modified to read: "it is not clear that the effects are fully reversible." Nero Calatrava (talk) 15:41, 20 December 2021 (UTC)

Your proposal is not substantiated by what you've quoted here. The statement as it exists currently in the article is supported by two high-quality MEDRS, including a review. Equivamp - talk 15:51, 20 December 2021 (UTC)

References

Questionable Reference

Reference 11 links to an obviously tendentious Article from Daily Signal. Sources on such a low level of impartiality shouldn't be used to back up scientific statements on a topic that is so highly politicized, no matter if these are factual or not. The Article itself cites an article from The New Atlantis as a source. This isn't even a proper scientific journal which is published by a judeo-christian conservative think tank. Finally, the New Atlantis article is written by authors who themselves are also controversial or biased at best. I would suggest to delete the corresponding sentence in this article until someone provides a proper source for this claim. Luftschiffpirat (talk) 20:02, 28 June 2019 (UTC)

Luftschiffpirat, Thanks for pointing out this recent addition. I have removed the sentence as the source obviously does not meet the requirements of WP:MEDRS. Feel free to edit the article and remove such sentences yourself! Galobtter (pingó mió) 08:56, 29 June 2019 (UTC)

Reference 15 does not support the claim being made concerning bone mineralisation. What it actually claims is "while children treated with GnRHa have a diminished bone accrual during treatment, it is likely that BMD is within the normal range after cessation of therapy by late adolescent ages."

Furthermore, studies have shown that calcium supplements during treatment negates this problem. ('Prevention of bone demineralization by calcium supplementation in precocious puberty during gonadotropin-releasing hormone agonist treatment' Antoniazzi F, Bertoldo F, Lauriola S, Sirpresi S, Gasperi E, Zamboni G, Tató L _ J Clin Endocrinol Metab. 1999 Jun; 84(6):1992-6) Eun Young Kim ('Long-term effects of gonadotropin-releasing hormone analogs in girls with central precocious puberty' 2015 Jan; 58(1):1-7 Korean J Pediatr https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342775/) discusses various research that all conclude that with or without calcium supplements bone mineralisation returns to normal within 2 years of stopping treatment.

Reference 15 seems to be being used to make false claims that the puberty blocker causes infertility - false as in there are multiple instances of people going on to become pregnant and have children in later life after stopping the blocker (see: https://academic.oup.com/jcem/article/84/12/4583/2864749 https://academic.oup.com/jcem/article-abstract/67/2/368/2651998 )

Technically, two pregnancies are multiple instances, but two births among 50 women is not a lot. 08:42, 3 March 2022 (UTC) — Preceding unsigned comment added by WordwizardW (talk • contribs)