Langbahn Team – Weltmeisterschaft

Talk:Cass Review

sources for consideration

See Also

@Snokalok and @Raladic You have added and reinstated a link to the page 21st-century anti-trans movement in the United Kingdom which you have been busily creating for the past few weeks.

That page has a somewhat inflammatory title to suggest an association with the Cass Review.

It also is justified by you because it contains the following:

In 2024, the publication of the controversial Cass Review of youth gender services led to a criminal ban on puberty blockers, and a general shift in NHS policy towards gender exploratory therapy, which many experts say is a form of conversion therapy. The review's recommendations were generally welcomed by the British medical community, however the international medical and academic communities generally criticised or rejected the review on grounds of both methodology and findings.

Which of course is not a reflection of the language on this page. I suggest this material is a WP:POVFORK and the relation to this page tenuous at best, especially the weasel-worded material on conversion therapy, which is itself flatly contradicted by the Cass Review. Void if removed (talk) 18:18, 4 December 2024 (UTC)[reply]

Please remember that Wikipedia is WP:NOTCENSORED and while you may take personal issue with the topic, it is a well sourced and neutral article that summarizes the anti-trans movement in the United Kingdom.
The article discusses the Cass Review in context, in fact it is mentioned 18 times in the article, so it is entirely appropriate as a related article link. Raladic (talk) 18:22, 4 December 2024 (UTC)[reply]
It’s a highly controversial government report that was used to justify a ban on puberty blockers and the mainstreaming of GET, which is widely recognized but everyone but the Cass Review as a form of conversion therapy. How is that not highly relevant to a major sociopolitical movement which has for a long time made both of those goals a centerpiece of itself? Snokalok (talk) 18:54, 4 December 2024 (UTC)[reply]
I don't think your repeated comments about GET are helpful.
In the final report, I find this:
"Terms such as ‘affirmative’ and ‘exploratory’ approaches have been weaponised to the extent that it is difficult to find any neutral terminology... 11.6 The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve."
It sounds like the twin goals are:
  • "not to change the person’s perception of who they are" – which means not conversion therapy – and also
  • "explore their concerns and experiences and help alleviate their distress".
Do you have a preferred term for this combination of not trying to change people's identities while still letting them have what one GIDS specialist calls "an open space for exploration of what this means to the individual, and what support they need in order to live a happy and fulfilled life"? The GIDS staff said they considered this to be compatible with the affirmative model, which they described in the report as "respecting the young person’s experience and sense of self whilst still exploring the meaning of that experience in a non-directive therapeutic relationship". Do you believe that this is a non-affirming approach? I could imagine someone (e.g., on social media) agreeing that this is actually an affirming approach, and agreeing that it is literally the approach recommended by the final report, but worrying that there will be a bait-and-switch scam: The Cass report might say not to change the clients' identities, but all of us smart people know that means exactly the opposite. WhatamIdoing (talk) 08:23, 5 December 2024 (UTC)[reply]
This goes back to the points I made here and the continual refusal to actually balance that material with the Cass Review over the past year. Unpicking this is hard, because it means an assessment of both the included and excluded sources over there. Which I did. But I am in a minority, and so this will keep spilling over onto this page.
Eg. Clayton et al (2024) says:
In contrast, Cass notes that alongside biological factors, psychosocial circumstances (such as trauma, homophobia, social influence) and mental health conditions might contribute to the development of youth GD/GI, rather than just being secondary or coincidental. Under the Cass model, the multidisciplinary assessment is geared towards identifying elements in these various domains relevant to the individual patient’s GD/GI. Cass notes the critical importance of a formulation to inform an individualized management approach which is developed by a collaborative process considering patient values, clinical expertise, and research evidence.4 In this model, GD/GI may well resolve with maturity, treatment of any co-existing psychiatric conditions, and/or supportive psychosocial care or psychotherapy – such as trauma-informed therapy or family therapy as indicated for each individual case. Importantly, this type of therapy does not aim to ‘change someone’s identity’ but validates a young person’s experience while opening space for self-reflection about their experiences and help with alleviating distress. This is not conversion therapy.
This could scarcely be clearer. However, since all three authors are associated with SEGM, and since editors have already decided SEGM are really espousing "conversion therapy" and are therefore fringe, the chances of my successfully citing this over such objections is nil, as with the arguments against the various BMJ sources that have been excluded from this page. Ie, it does not matter that this is a high quality peer-reviewed source, saying explicitly that it isn't conversion therapy, editors seem to already know it is (largely based on the current state of Gender exploratory therapy and SEGM), and that these authors can't be trusted, and thus it is excluded.
Likewise, Roberto D'Angelo, president of SEGM, writing in September:
Further, the current dominant understanding of trans identification in young people entails a very specific way of formulating (I would argue distorting) psychological distress, described in The Cass Review as “diagnostic overshadowing”. In effect, what this means is that any suffering, manifesting as anxiety, depression, eating disorders, etc, is subsumed under the diagnosis of gender dysphoria or “massive gender trauma”. This reconfiguration effectively trivialises and even erases these problems and their meaning, viewing them as secondary phenomena that will evaporate once gender transition has occurred. This clinical process reshapes psychic pain, which is difficult for both patient and analyst to bear, into a concrete problem with a concrete solution. Those who raise concerns about the quality of the evidence base for this concrete solution present a threat to this defensive phenomenon and are attacked with the same ferocity encountered when a patient becomes aware of dissociated material or “not-me” states. The net effect is that both analyst and patient can avoid and deny the psychic pain that is “humming” beneath the experience of gender dysphoria, maintaining a powerful prohibition on knowing.
Again, these are by my reading legitimate perspectives expressed in respectable, peer-reviewed journals. But if you start from the position that it is conversion therapy and cannot be legitimate (and is therefore fringe) then it creates a self-perpetuating cycle where no balancing sources are ever acceptable, because by saying the "wrong" thing they are fringe, something that has been applied even to sources as weighty as the Cass Review. It is WP:EXTRAORDINARY to claim the Cass Review espouses conversion therapy.
Do you have a preferred term
There is no preferred term. There cannot be one. The split is between the affirmative model, and anything else. If it isn't the affirmative model, then it is considered de facto conversion, and any labelling is mere obfuscation, is the reasoning. Exploratory therapy, gender exploratory model, psychotherapy, psychoanalysis, psychodynamic psychotherapy, ethical exploratory therapy, non-directed exploration - these have all been used and every single one has been collapsed into "conversion therapy". Cass drew attention to this as part of the reason GIDS was overwhelmed and failed - because clinicians didn't want to risk engaging in bog standard psychotherapy themselves and just dumped patients to GIDS. Void if removed (talk) 09:52, 5 December 2024 (UTC)[reply]
Diagnostic overshadowing could use some work. I wonder if the outrageous experience some trans people have reported, of having a provider ask to look at their genitals when they have a broken ankle, could be a case of this.
I suspect that it's mostly meant to cover cases of "He's screaming again so that's just his Level 3 Autism, not a sign of physical pain", but I haven't looked for sources that would show how narrow or wide it's usually understood. WhatamIdoing (talk) 17:29, 5 December 2024 (UTC)[reply]
Well quite, and in the context of the Cass Review the refusal of the adult clinics to provide follow-up information makes much of this unfortunately poorly understood. The outcome data is so poor it's hard to say with certainty. Void if removed (talk) 20:56, 5 December 2024 (UTC)[reply]
Ok, but regardless of what SEGM may or may not be saying on this particular subject, they are still a fringe group that hold scientifically unsupported positions, so they & those closely affiliated with them should not be cited as reliable sources for medical/scientific topics. Butterscotch Beluga (talk) 20:35, 5 December 2024 (UTC)[reply]
@Butterscotch Beluga, can you point me to the policy or guideline that says if someone holds a fringe position that nothing they write, and nothing written by anyone closely affiliated with them, can be cited as reliable sources for medical/scientific topics?
If you are looking for an example from another field, Linus Pauling won a Nobel for chemistry, and part of that work developed into proving that Sickle cell disease is genetic. He also advocated for fringe-y positions on Vitamin C megadosage. Now, according to what you've said, there's a policy or guideline that says Pauling can't be cited "for medical/scientific topics". Which policy or guideline is it, and what's the exact wording in it? WhatamIdoing (talk) 20:52, 5 December 2024 (UTC)[reply]
I feel that's a poor example.
Linus Pauling has some ideas that are very well accepted, and others which have been dismissed as quackery. Same with other semi-quacks such as John Ioannidis.
I think if multiple folks state that Linus Pauling's views on medical info post 1960 is inflammatory, his statements should be given attribution, alongside the appropriate criticism. If he is well respected in electrochemistry, and pre1960-ish, it would be undue not to include him.
We can include SEGM as long as we attribute to them, and if there is sufficient criticism, we provide the WP:DUE amount of context around them. Bluethricecreamman (talk) 21:06, 5 December 2024 (UTC)[reply]
That's not what Butterscotch Beluga was saying. WhatamIdoing (talk) 21:36, 5 December 2024 (UTC)[reply]
That actually was what I was saying. When I said "for medical/scientific topics", I did indeed mean in the context that they are considered fringe.
This I hope properly conveys why I don't think those who are members/have close relations with SEGM are reputable, nor should their positions related to SEGM's subjects of advocacy carry much weight. Butterscotch Beluga (talk) 22:00, 5 December 2024 (UTC)[reply]
I wonder occasionally if it would be worth setting up a section similar to the Talk:Donald Trump#Current consensus section (which, in general, I think is a terrible idea), in which we record some things that we all agree on, e.g., that citing something written by an SEGM-tainted person does not automatically violate any policy or guideline, or that the Integrity Project's paper is not peer-reviewed, or whatever little facts we've discussed more than once or twice.
Butterscotch Beluga, I don't really care why you/we/anyone consider them disreputable. What I care about is whether Wikipedia editors post non-existent, made-up rules, which are then read and sincerely believed to be The Truth™ by less experienced editors. If you write something like "The policy says SEGM can't be cited for medical/scientific topics", then even if most of us know that this is just a quick thing, to get the general gist across, someone is eventually going to read that and believe that there is an actual WP:Policy that actually says this. This is a consequence of our method of teaching Wikipedia's rules, which is basically the telephone game. That's not your fault, but it is something you can help with. So I ask: Please (everyone), be careful about what you describe as being required or prohibited by policies and guidelines. It'll save everyone a lot of hassle and drama in the end. WhatamIdoing (talk) 22:33, 5 December 2024 (UTC)[reply]
I didn't say "The policy says SEGM can't be cited for medical/scientific topics" & as such, I'm not sure why you're putting it in quotes.
I'm saying that if someone works with a group with controversial views on conversion therapy, we shouldn't cite them uncritically on what is/isn't conversion therapy. Butterscotch Beluga (talk) 00:30, 6 December 2024 (UTC)[reply]
Right. Your exact words above were they & those closely affiliated with them should not be cited as reliable sources for medical/scientific topics.
Quotation marks in English have multiple uses; marking exact quotations of prior speech is only one of the multiple uses. WhatamIdoing (talk) 00:44, 6 December 2024 (UTC)[reply]
Ok. Personally, I don't like using quotation marks if I'm not quoting someone/something specifically, as it may lead to miscommunication, but that's neither here nor there. Butterscotch Beluga (talk) 00:47, 6 December 2024 (UTC)[reply]
This is a non-independent source, engaged in legal action in the US in opposition to SEGM so should be taken with a pinch of salt, especially in light of this peer-reviewed critique of the Yale team in the BMJ.
Which has of course been discussed here previously, and been derailed - again - by one of the co-author's relation to SEGM, never mind that the others are not.
The problem here is that on the balance of sources, we have a difference of opinion.
But if you start from the position of SEGM are fringe, that balancing of sources never happens. Void if removed (talk) 22:33, 5 December 2024 (UTC)[reply]
This might seem like a tangential response, but I'm looking at the BMJ critique you linked & was wondering if you could help clarify something for me.
It says "Various versions of McNamara et al have already been introduced into evidence in at least two high-profile court cases", but despite the two citations they supply, I'm having issues finding any mention of McNamara in either case.
Citation 16's google scholar link only finds the original BMJ critique & citation 17 does link to a case (Specifically this), but I don't see where McNamara et al is being used as evidence.
I'm probably just misunderstanding how google scholar works/am missing something obvious, but I wanted to check if you knew what the issue I'm having is. Butterscotch Beluga (talk) 23:56, 5 December 2024 (UTC)[reply]
Google Scholar does not track documents in lawsuits. Try searching a specialist website like this one: https://www.courtlistener.com/docket/63252064/eknes-tucker-v-marshall/?page=4 Or just try your favorite web search engine.
The SCOTUS case documents are here: https://www.supremecourt.gov/search.aspx?filename=/docket/docketfiles/html/public/23-477.html WhatamIdoing (talk) 00:52, 6 December 2024 (UTC)[reply]
RE: the first, the Yale critique of the Cass Review was filed as an amicus brief in Boe vs Marshall the day it came out, you can read it here: https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.629.7.pdf
From here:
https://www.courtlistener.com/docket/63252064/boe-v-marshall/?page=4 Void if removed (talk) 16:25, 6 December 2024 (UTC)[reply]
I don't think this statement actually shows that GET isn't conversion therapy. Having read the article in sandbox as well, I'm even more suspicious of this approach. All the talk of meaningmaking and finding a formulation suggests a process of looking to attribute transness to underlying psychological conditions. Once such "meanings"/conditions have been identified, the therapist is obliged to treat them per oath. Whether they intend to or not, this then becomes an attempt to treat transness itself – the transness becomes a medical problem to fix – and is thus conversion therapy.
The name is also a giveaway of intentions. Gender exploratory therapy isn't neutral, and isn't simply exploration and investigation; it means starting from the position of assuming a need to treat. The treatment begins before the rationale has even been developed, and you just make up the rationale (sorry, "find the formulation") as you go along. And this "psychological intervention" is also mandated before you can access anything else.
But all this aside (I know, I know, Wikipedia is WP:NOTAFORUM), most experts internationally do see GET as conversion therapy. As did many UK experts until recently. We aren't bound to enforce UK policy changes or new report findings, only the consensus among experts. And WP:SPOV trumps government reviews. If the UK and a couple of other countries are outliers, then they naturally represent a minority viewpoint and not the consensus, and should be presented as such. Lewisguile (talk) 10:26, 20 December 2024 (UTC)[reply]
SPOV is a {{failed proposal}}, and NPOV says that the views of Wikipedia editors – including whether Wikipedia editors deem a particular POV to be "scientific" – are irrelevant. WhatamIdoing (talk) 22:57, 20 December 2024 (UTC)[reply]
You ignored the bit about most international experts disagreeing with the UK view. The UK is therefore an outlier. Lewisguile (talk) 13:02, 21 December 2024 (UTC)[reply]
I responded only to your claim that And WP:SPOV trumps government reviews.
I wonder, though, whether it's really appropriate to talk about "international experts". WPATH claims to represent/serve the world, but much of the world (e.g., developing countries) is not especially interested in its views. We're kind of in a position of having UK+Norway+Sweden vs US+AU+NZ+some others vs a majority of countries that explicitly prohibit transition or have no legal provision for it. "The international consensus", if you determine this by population or the number of countries, is that trans people get no medical care and have no legal rights. Perhaps we should talk about "the scholarly consensus"? WhatamIdoing (talk) 19:40, 21 December 2024 (UTC)[reply]
We can call it that if you'd like. "International expert consensus" might be the best framing, but we're splitting hairs. Lewisguile (talk) 20:13, 21 December 2024 (UTC)[reply]
What's the difference between an "international expert" and an "Australian expert"? WhatamIdoing (talk) 22:44, 21 December 2024 (UTC)[reply]
I'm not sure this is a fruitful line of discussion, TBH. With all the good faith I can muster, I have still found most your responses a combination of pedantic, sometimes a little combative and often baffling. I'm often not sure what you're trying to say or why. I feel like there's no way to engage constructively with them at present but I don't want to ignore you completely, because it seems you are trying to say something useful. It's entirely possible I'm just not understanding your response style or what you're trying to convey, but that's as good a sign as any to leave this line of thought well enough alone. Thanks anyway. Lewisguile (talk) 08:57, 22 December 2024 (UTC)[reply]
I'm also finding some of this confusing, which is why I'm asking questions.
AFAICT the answer to my question is that if the source agrees with the True™ POV, then they're an international expert, but if the source disagrees with the True™ POV, then that's only a country-level expert (at best). So if an Australian expert writes something that aligns with their country's approach, then they're an "international" expert, but if a Norwegian or Swedish expert writes something that aligns with their country's approach, then they're not. Right?
If so, then maybe we should say "WPATH's SOC-8" instead of "international expert consensus". It would be more specific and more neutral, as well as preventing confusion about why the "international" consensus is rejected by a majority of countries. WhatamIdoing (talk) 06:50, 23 December 2024 (UTC)[reply]
The international consensus is the medical opinion of the big international organizations in this area of medicine, namely WPATH and the Endocrine Society. It's true that there are specific experts and even sometimes whole national health organizations that contradict them, but in order to be the international consensus, they would have to either get WPATH and the ES to agree with them, or make an organization that was as big and influential in the area as WPATH and the ES are. Loki (talk) 03:58, 25 December 2024 (UTC)[reply]
Which is to say that the "international consensus" is "the agreement of two US-based organizations". I think we should consider being more specific (e.g., "Cass rejected the treatment protocols from WPATH and Endocrine Society, which are the most widely used in the world").
"International" in medicine usually means a UN agency, especially the World Health Organization. When describing a protocol that is widely used around the world (e.g., the CHOP-R chemo protocol), nobody bothers to call it an "international" protocol; it would feel weird – like your science is so weak that you need to slap on some peacock words for marketing purposes. WhatamIdoing (talk) 17:41, 25 December 2024 (UTC)[reply]
The UN is also US-based, though. Its headquarters are in New York.
More to the point, it's true that the US has an outsize amount of influence in many international organizations. But that doesn't make them not international. WPATH and the Endocrine Society are both very clearly international organizations according to all sources on them and your attempts to argue against that sound frankly like WP:IDONTLIKEIT to me. Loki (talk) 03:48, 26 December 2024 (UTC)[reply]
The UN isn't US-based, though its main headquarters are there. The UN was founded by multiple countries working together.
The WPATH article, on the other hand, says "The founding committee was entirely American...", and it looks like most of the past presidents were from the US. WhatamIdoing (talk) 04:07, 26 December 2024 (UTC)[reply]
So? Again, it's true that the US has an outsize amount of influence in many international organizations, but that doesn't make them American organizations. NATO was established in America and has been very clearly dominated by the US throughout its history, and yet it's clearly an international organization. And WPATH isn't even nearly so American-dominated as that.
This whole argument feels like a clear no true Scotsman to me: no true highly respected international WP:MEDORG would take such a strong stance on one side, therefore WPATH must be fake or illegitimate for some reason. Loki (talk) 02:04, 27 December 2024 (UTC)[reply]
Both NATO and its predecessor were formed by a treaty, which means that NATO was inherently an international project from the beginning.
Highly respected international MEDORGs do (and IMO should) take strong stances. What feels "off" to me is that we have two US-dominated orgs that Wikipedia editors have repeatedly presented not as being "right" (or equivalents, e.g., "evidence-based"), but instead as "the international consensus", which is abnormal for a MEDORG. Compare some other, once-contentious claims:
  • Measles vaccines do not cause autism.
  • The CHOP-R chemotherapy regimen is widely used because it has the same survival rate but lower side effects than the alternatives.
  • Antibiotics do not cure viral infections.
  • Screening mammograms are inappropriate for women whose expected lifespan is short (<10 years).
  • Breast self-exams don't save lives.
  • HIV causes AIDS, but Undetectable = Untransmittable.
But:
  • There's an international consensus that (some) trans kids should be eligible for hormone treatment before the age of 18.
Which leads one to wonder: How many other consensuses are out there, and do all of them disagree?
In the other examples, we don't need to prepend "There's an international consensus that...", because it's just facts, and everyone (i.e., every expert) around the world knows and agrees with these facts. So why is that necessary here? From where I'm sitting, it certainly sounds like it's because the "international consensus" isn't as widely agreed-upon as these other things. WhatamIdoing (talk) 04:52, 27 December 2024 (UTC)[reply]
The York review on international guidelines says that the majority of such guidelines are based on those by WPATH and the Endocrine Society. It does describe differences on specifics, but it also says, Overall, guidelines describe a care pathway similar to the original Dutch protocol that involves psychosocial care for prepubertal children followed by hormonal interventions for adolescents who meet specific criteria, provided by a specialist multidisciplinary team. This approach continues to dominate clinical guidance despite lack of high-quality evidence regarding treatments, or exploring alternative care models. Earlier it says, All but one of these promote a model of gender-affirming healthcare, which seems quite clear to me.
Their own conclusion was Published guidance describes a similar care pathway; however, there is no current consensus about the purpose and process of assessment for children or adolescents with gender dysphoria/incongruence, or about when psychological or hormonal interventions should be offered and on what basis. So the lack of consensus, per York, is in regards to the assessment process and when and why to offer interventions, not in the interventions themselves (the overall "pathway" is described as being broadly similar several times). From this, we can derive the following:
  • Most GLs internationally are based on WPATH and/or the Endocrine Society
  • All but one of the GLs advocate a "gender-affirming" model
  • Most GLs describe the same or a similar pathway
  • GLs differ on the specifics of when and why interventions are given (which isn't the same as saying they differ on which interventions are given)
  • GLs differ on the specifics of why assessment is conducted
Therefore, it's fair to say there's a consensus for gender-affirming care based broadly on the Dutch model, but that variations and rationales differ in key areas. The Cass Review, also drawing on the e-survey on service delivery, concludes that Most national and regional guidelines have been influenced by the World Professional Association for Transgender Health and Endocrine Society guidelines which themselves lack developmental rigour and are linked through co-sponsorship. There is consensus across guidelines that those requiring specialist gender care should receive a multi-disciplinary assessment, although there is a lack of clarity about who should be involved in this and any differences in assessment for children and adolescents. Similarly, there is consensus that children and adolescents should be offered psychosocial support, but there is limited guidance about the process or approach for this and different recommendations about whether specialist gender clinics or mental health services should provide this. There are differing recommendations about when and on what basis psychological and hormone interventions should be offered, and limited guidance about pre-pubertal children or those with a non-binary gender identity. Cass isn't saying there isn't any agreement, but that there is divergence on key specifics, as per the York review; that the evidence base for them isn't robust enough; and that service delivery models are different in different places (unsurprisingly). WPATH, of course, disputes that its guidelines are unreliable (as do other orgs) as per the current "Responses" section. When we separate out the service delivery elements (which is driven by budget, politics, local need, etc, and isn't necessarily defined by treatment guidelines but rather by the operationalisation of them), Cass is simply reiterating the York review on international guidelines (as we'd expect). So my summary above stands here too. Lewisguile (talk) 07:45, 27 December 2024 (UTC)[reply]
The York review covers international, national, and regional guidelines. It cites a 2021 paper that defines "international guideline" as a guideline intended to apply across multiple nations (most commonly, the EU or globally). They found 12 such international guidelines (Table 1): the 2017 Endocrine Society guideline, WPATH's SOC-7, a speech/language guideline based on SOC-7, and nine others that weren't based on either of the two big US-based groups, several of which are only partially about gender care, but some of which are highly relevant for the subject of the Cass Review (e.g., "Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents"). Some of these criticize ES and WPATH (e.g., based on "limited" evidence or being out of date), though I haven't noticed any that fully reject either. WhatamIdoing (talk) 21:15, 27 December 2024 (UTC)[reply]
Let me rephrase. Void if removed referred to the York review as the "York review on international guidelines" and I was using the same language. We were both referring (I think) to the overall findings of the "York review on guidelines"; in my case, I used "international" to mean "not UK"/"beyond UK", rather than specifically "GLs intended to apply across multiple countries". Cass' synthesis/conclusions seem to draw from across these GLs, without distinction for whether they're regional, national, etc. She makes her conclusions based on broad similarities and specific differences across the entirety of all the GLs, so that's what I've done too. Lewisguile (talk) 08:09, 28 December 2024 (UTC)[reply]
The York review of international guidelines tells us there is no international consensus. Void if removed (talk) 21:30, 26 December 2024 (UTC)[reply]
Where in the York review on guidelines does it mention conversion therapies? I didn't spot that on my recent re-read, so a page reference would help. Re: guidelines, it finds lack of clarity in specifics but says most guidelines are based on the same two guidelines (WPATH and Endocrine Society). Consensus is therefore largely around following the WPATH and Endocrine Society GLs, but obviously there is greater divergence thereafter. It also says:
  • "Guidelines describe a similar care pathway starting with psychosocial care for prepubertal children, puberty suppressants followed by hormones for eligible adolescents and surgical interventions as these adolescents enter adulthood."
  • "In general, there is consensus that adolescents should receive a multidisciplinary assessment, although clear guidance about the purpose or approach is lacking. There are differing recommendations about when and on what basis psychological and medical interventions should be offered. There is limited guidance about what psychological care should be provided, about the management of prepubertal children or those with a non-binary gender identity, nor about pathways between specialist gender services and other providers."
  • "Two guidelines explicitly adopt the Dutch model (the earliest paediatric treatment protocol), and most guidelines reflect this pathway. One of these, however, recommends that medical interventions occur under a research framework and modifies the original criteria for treatment. Four guidelines propose an individualised approach to medical interventions, while still describing a phased approach"
  • "All but one of these promote a model of gender-affirming healthcare and indicate that those with 'a stable gender identity' and 'supportive family and school environment' may not require psychosocial care. This recommendation marks a departure from earlier guidelines which describe psychosocial care as the mainstay of treatment, and the recent Finnish and Swedish guidelines which describe it as first-line treatment for childhood gender dysphoria/incongruence."
  • "Overall, guidelines describe a care pathway similar to the original Dutch protocol that involves psychosocial care for prepubertal children followed by hormonal interventions for adolescents who meet specific criteria, provided by a specialist multidisciplinary team. This approach continues to dominate clinical guidance despite lack of high-quality evidence regarding treatments, or exploring alternative care models" (So this last part is what I would say the consensus is beyond Cass. Recognising divergence from consensus doesn't negate consensus, and in some regards, the differences can be seen as matters of clinical judgement or service priority.)
Lewisguile (talk) 21:53, 26 December 2024 (UTC)[reply]
What you're doing there is recounting the POV of those who say exploratory psychotherapy is conversion therapy. This is of course one POV, and one which needs to be fairly represented in relevant articles.
But it is not the only POV, nor is it the only POV present in MEDRS, which are much more equivocal on this, nor is it a POV that can be taken as definitive and used to judge the validity of different POVs in MEDRS. Indeed, the most definitive statement in a high quality source comes from the Cass Review, explicitly stating that it is not conversion therapy, and that it is harmful to suggest it is.
As Cass said in a recent interview:
There are individuals who are saying that [psychological] therapists who just take that careful, exploratory approach with a young person are conversion therapists, and that’s why it becomes so difficult, because then those therapists working in that space who are getting attacked become fearful Void if removed (talk) 13:44, 21 December 2024 (UTC)[reply]
The way to deal with this is not to look at only one source (e.g., the Cass Review), but to look at the breadth of sources in English and what the consensus among them seems to be. On the matter of whether "exploratory psychotherapy" (which doesn't seem to be a clinically defined term, as far as I can tell) is conversion therapy or not, it would be useful to consult what experts on trans health and conversion therapy say, and if there's any consensus between them? If there isn't, then we try to portray the major disputes. We certainly shouldn't ignore any major differences of opinion to push only one side, whether that's solely the view of the Cass Review or solely the view of anyone else.
If exploratory psychotherapy isn't well defined, then we may run into a problem there, too. But we can deal with that bridge when we come to it. Lewisguile (talk) 09:02, 22 December 2024 (UTC)[reply]
Another way would be to conduct a systematic review of international guidelines to determine what the consensus was on the appropriate psychotherapeutic interventions, at what point, to what end, what outcomes are expected etc. Which of course the Cass Review did, and found there to be no international consensus.
I think you might be mistaking strongly-expressed positions for international consensus.
As an aside, it is worth reviewing the recent Italian National Bioethics Committee position (Italian, but machine translation is good). What is fascinating (to me at least) about this is that despite a near-unanimous statement in accordance with the findings of the Cass Review signed by numerous clinical experts, after a year of taking evidence, resulting in advice to restrict puberty blockers to a clinicial trial context, almost half of this publication (9 pages) is given over to the opinions of a single dissenter and a single abstainer.
In this thread you have very effectively put forward broadly the same position as the dissenting voice. That's fine, these are valid (and in some contexts majority) positions, and should be fairly represented. But they are not the only POV, and in some contexts they are outliers.
Navigating this neutrally is hard, when there is genuine dispute in MEDRS and widely varying expert opinion - and when the center of gravity for the strongest opinions is the US, and deeply enmeshed in US politics and legal struggles, that makes it even harder. But I'm afraid there simply is no international medical consensus that we can all straightforwardly defer to on any of these matters, the most comprehensive evidence-based independent review in this area is still the Cass Review, and the claims that the Cass Review espouses conversion therapy are WP:EXTRAORDINARY. Void if removed (talk) 12:15, 22 December 2024 (UTC)[reply]
The Cass Review is also just one source. Consensus is determined based on representing the balance of all major viewpoints, including those which dissent. So the Cass Review's conclusions are Cass' opinions based on systematic reviews, stakeholder consultation, grey literature, etc'.' The tools at her disposal may have been better than most (or even all) alternatives, but she still had to interpret that evidence to make her own conclusions from those tools. Which is why we still consider it one source among many. It can be appropriately weighted, but it isn't the be-all and end-all on the matter. It's about as useful and authoritative as a NICE guideline or Cochrane review, but unlike them, is significantly less transparent and vests decision-making in a single individual rather than a committee.Lewisguile (talk) 19:06, 22 December 2024 (UTC)[reply]
If this were an article about medical care for trans people in general, I would agree with you, but since this is an article about a document, then the due weight calculation is a bit different. It's not just "one source among many"; it is "the subject of the article". WhatamIdoing (talk) 06:52, 23 December 2024 (UTC)[reply]
If the article is indeed a WP:POVFORK of something you should propose merging or nominate it for deletion instead of removing links. Flounder fillet (talk) 18:16, 5 December 2024 (UTC)[reply]
I think it's unrelated, inflammatory, and adds nothing to this page. It shouldn't be in see also. I the idea that I cannot simply say the link shouldn't be there, but must instead be drawn into wider content arguments about a page I have no interest in and that has no bearing on this one. Void if removed (talk) 21:03, 5 December 2024 (UTC)[reply]
Bandying claims of POVFORK then saying it is entirely unrelated to this page are not compatible arguments. Bluethricecreamman (talk) 21:07, 5 December 2024 (UTC)[reply]
I disagree. The subject is nothing to do with this page. It also contains POV descriptions of the Cass Review. These are orthogonal concerns.
Not every page that mentions the Cass Review belongs in See Also, that's what "what links here" is for. The fact is the principal subject of that page has nothing to do with this one, and suggesting it does is inflammatory. Void if removed (talk) 21:27, 5 December 2024 (UTC)[reply]
No, the article discusses the Cass Review against the wider backdrop of the anti-trans movement in the UK and how it is being weaponized by anti-trans fringe groups, so this connection between the articles is very clear and the See Also is appropriate. This opposition appears to be a clear case of WP:IJUSTDONTLIKEIT. Raladic (talk) 21:46, 5 December 2024 (UTC)[reply]
According to MOS:SEEALSO articles linked should be related to the topic of the article or be in the same defining category.
21st-century anti-trans movement in the United Kingdom is unrelated to the topic of this article.
I can't find any decent independent sources making such a connection. There's this (which is not a reliable source), there's this (which is a garbage source that contains outright misinformation from the headline onwards) and there's this (which talks about the anti-trans movement in the US, not the UK).
The premise of your inclusion of the Cass Review in this article seems to be your own POV that it belongs there, and now you're reasoning backwards to say it is relevant, because your article says so. Void if removed (talk) 23:04, 5 December 2024 (UTC)[reply]
They both share several defining categories , most prominently Category:LGBTQ-related controversies in the United Kingdom and Category:Transgender topics in the United Kingdom and Hillary Cass's own statement in the article In an interview with The New York Times in May 2024, Hilary Cass expressed concern that her review was being weaponized to suggest that trans people do not exist... - this is the weaponization of the Cass Review that anti-trans groups are doing that she's referring to.
Again, the other article has several citations and links to the Cass Review, there is a clear link of the topics, so this see also link is entirely reasonable. Raladic (talk) 23:12, 5 December 2024 (UTC)[reply]
The Cass Review has been a corner stone of anti-trans advocacy since its release, and has been cited as the primary motivator for anti-trans policies such as Victoria Atkins puberty blocker ban. The link between the Cass review and the anti-trans movement is evident, and there is no scarcity of references which can be cited. Here is one example, which cites a government barrister saying that "Atkins “acted on the basis of her personal views about the conclusions of the Cass Review” : https://www.independent.co.uk/news/uk/crime/victoria-atkins-nhs-high-court-secretary-of-state-london-b2578759.html HenrikHolen (talk) 01:53, 6 December 2024 (UTC)[reply]
A page having POV issues is not equivalent to it being a WP:POVFORK. Flounder fillet (talk) 01:22, 6 December 2024 (UTC)[reply]
This comment feels like it falls into the category of WP: I Just Don't Like It.
The Cass review has motivated significant rollbacks of transgender rights in the UK. It is undeniably pertinent.
HenrikHolen (talk) 22:04, 5 December 2024 (UTC)[reply]
@Partofthemachine This is the discussion about the "See also". Please feel free to add your thoughts also, as people are still contributing (albeit more slowly than at first). Lewisguile (talk) 08:15, 28 December 2024 (UTC)[reply]

Enforced BRD

Just so nobody misses this: There's a thing called 'enforced BRD', and it now applies to this page. That means that the rules used to be:

  • Make your edit
  • Get reverted
  • Maybe restore your edit (but never to the point of edit warring)

and they are now:

  • Make your edit
  • Get reverted
  • Start a discussion on the talk page (or just decide to never restore your edit)
  • At least 24 hours after starting that discussion, you can maybe restore your edit (but never to the point of edit warring, nor if the discussion on the talk page has active opposition. Silence is not active opposition).

See User:Awilley/Enforced BRD FAQ and User:Awilley/Consensus Required vs Enforced BRD for more information.

WhatamIdoing (talk) 04:04, 11 December 2024 (UTC)[reply]

Glad to see this - is it wrong that I think this should be mandatory on GENSEX? Void if removed (talk) 18:06, 11 December 2024 (UTC)[reply]
I think you would be surprised how cumbersome it can be, especially for problems like subtle vandalism. WhatamIdoing (talk) 18:29, 11 December 2024 (UTC)[reply]

EBM as motivation

Hi @Snokalok, hope you're doing well.

I've seen you've undone my edit explicitly saying that enabling EBM was a motivation for the systematic reviews and Cass Review as a whole. Fundamentally, this is what the systematic reviews were for: to see the extent to which different types of transgender healthcare are supported by scientific evidence. Furthermore, it's supported by both the sources used for the sentence I changed.

Thornton said: "Fundamentally, Cass says that children with gender incongruence should receive the same standards of high-quality, evidence-based care expected elsewhere in the NHS. “They deserve very much better”, she wrote. Cass commissioned four systematic reviews of the evidence on key issues, including puberty blockers, hormones, and clinical guidelines."

The Cass Review itself said (amongst other quotes): "Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way. Whilst navigating a way through the surrounding ‘culture war’, the Review has been acutely and increasingly aware of the need for evidence to support its thinking and ultimately the final recommendations made in this report."

Please let me know what you think when you have time. Thanks! 13tez (talk) 20:17, 17 December 2024 (UTC)[reply]

So, there are a couple points I’d raise.
First, I feel that given the contested nature of the review among the medical and academic communities, statements like “we’re choosing EVIDENCE over SOCIAL JUSTICE” are something that at best need to be attributed and not simply repeated in wikivoice. Beyond that though, it is contested that Cass’ conclusions are the only evidence based ones, as seen in the response from countless MEDORGS below saying that the evidence does indeed support GAC and directly contradict the report’s conclusions. It’s a point that’s been rehashed countless times on this page as well, the basic “Only 13% of medical treatments have high quality evidence, citation cochrane” and the “why did the report say that psychotherapy had the same quality of evidence as HRT but recommended psychotherapy over HRT?”
I think that we can’t neutrally say that the Cass Review was doing this for EBM when we have countless MEDORGS contesting that in the article, as well as the BLUESKY on double standards of evidence here. Saying the Cass Review was done for EBM is at best a POV statement that we can perhaps place with attribution, but I’d argue not without the social justice part of the quote, and not without careful NPOV balancing that we’d have to work out on here beforehand. Additionally, regarding the systematic reviews commissioned, while they themselves are by all accounts fine reviews, the Cass Review itself is not a systematic review, it’s government recommendations made separately in response to those reviews and without any peer appraisal process.
I’m sort of rambling here, the point is, the EBM over social justice thing is in no way a neutral, scientifically vetted, or MEDORG uncontested statement and we shouldn’t be repeating it as though it is one. If you feel that it’s something still worth including based on notability (which I’ve not given strong consideration to yet), I’d like to hear that case more in depth. Snokalok (talk) 20:52, 17 December 2024 (UTC)[reply]
This comment (we can’t neutrally say that the Cass Review was doing this for EBM when we have countless MEDORGS contesting that) treats intention and result as the same thing. The review could be done "for the purpose of" evidence-based medicine but "actually result in" something else, just like a review of this type hypothetically could have been done "for the purpose of making sure the right political party won the next election" or "for the purpose of reducing healthcare costs" or "for the purpose of giving every child a lollipop", even if none of that is what actually happened.
If you want to contest a claim that the purpose/motivation was evidence-based medicine, then you need a source that says the intended purpose (i.e., not the actual outcome) was something else. WhatamIdoing (talk) 00:35, 19 December 2024 (UTC)[reply]
But the quotes you've given don't actually say "our intention is to reinforce EBM" or similar. You seem to be confusing intent with outcome. They have said the treatments weren't evidence based and they would like more EBM, but that was a finding. Lewisguile (talk) 07:56, 19 December 2024 (UTC)[reply]
Since I've given no quotes, you must be referring to a comment from someone else, but I can't figure out which comment you're referring to. WhatamIdoing (talk) 21:06, 19 December 2024 (UTC)[reply]
You're right! Sorry about that. I think I was replying to someone else and got lost in the branching replies. I've been ill on and off with COVID for the last two weeks, so I've had a bit of brain fog. Ignore me for now and if I figure out where this comment goes, I'll move it to the correct place. Lewisguile (talk) 14:56, 20 December 2024 (UTC)[reply]
I’m not saying that we should say it wasn’t for the sake of EBM, just that we can’t reliably or neutrally say it was given everything above. Snokalok (talk) 14:19, 19 December 2024 (UTC)[reply]
If we have sources saying that it was for the sake of EBM, then we can reliably say that; if we have no sources directly saying that it wasn't for the sake of EBM, it would even be neutral.
Note that one source saying "It was all motivated by a love for EBM, folks" is not contradicted by another source that says "But the result is a disaster!" We'd need a source that says something closer to "This was not motivated by EBM; this was entirely motivated by his political aspirations". WhatamIdoing (talk) 21:09, 19 December 2024 (UTC)[reply]
Such as the one medorg down below (PATHA) saying “This was a hit job by the people who pushed GAC bans in the US”? Snokalok (talk) 02:00, 20 December 2024 (UTC)[reply]
As I said, if you want to contest a statement that says that the motivation was EBM, then you need a statement that says it was not motivated by EBM. "This was a hit job" is not the same as "They were not motivated by EBM". WhatamIdoing (talk) 03:22, 20 December 2024 (UTC)[reply]
On that, I would respectfully disagree for two reasons:
1. Motivated by EBM implies a good faith dedication to science that a hit piece would not. Even if you disagree on this point, the fact remains that saying it was motivated by EBM carries a connotation of good faith and professionalism that is disputed by the latter statement, and thus we wouldn’t be presenting a neutral view.
2. The original quote above made a very strong point of saying ‘EBM over social justice’ which, besides lending credence to the hit piece idea, makes it inherently a politically aligned statement rather than a scientific one, and as such we can’t present it without neutral balancing or, at the very least, the full sentiment w/ the social justice part Snokalok (talk) 14:47, 20 December 2024 (UTC)[reply]
Hey, thanks for getting back to me. I hope you're having a nice day.
First, I feel that given the contested nature of the review among the medical and academic communities, statements like “we’re choosing EVIDENCE over SOCIAL JUSTICE” are something that at best need to be attributed and not simply repeated in wikivoice.
I don't think that framing accurately represents the point Cass was making. I think that she was explaining in good faith, to anyone who didn't already know, ⁣that while some people would advocate for other approaches, the NHS (and modern medicine in general) operates based upon EBM. NICE was created in 1999 to disseminate evidence and clinical guidance, based upon that evidence, to the NHS.
What she's saying is true, and she says that the transgender culture war is harmful. I can see why using the phrase "social justice" could, on first impression, make someone believe otherwise, since it is sometimes used in anti-trans and other reactionary rhetoric. However, she's making an explanation for transparency, to aid understanding, and in good faith here, rather than deriding anyone.
it is contested that Cass’ conclusions are the only evidence based ones, as seen in the response from countless MEDORGS below saying that the evidence does indeed support GAC and directly contradict the report’s conclusions
I don't think it's accurate or balanced to say that "countless" medical organisations either support the review or its findings or oppose it/them. Medical organisations in the UK, including the NHS and the RCP, generally support the review (the BMJ, amid controversy, is pending). WPATH and its regional branches, which some view as MEDORGs, have criticised it. Some international medical organisations, such as the American Academy of Pediatrics, have criticised the review and/or contradicted some of its findings. Regardless, the Cass Review's findings are based upon the systematic reviews, which are the highest level of evidence in medical research and were commissioned by the NHS, one of the few "reputable major medical and scientific bodies" explicitly listed as a suitable source for medical information at WP:MEDORG. It is based upon an extremely high-quality body of evidence.
“Only 13% of medical treatments have high quality evidence, citation cochrane” and the “why did the report say that psychotherapy had the same quality of evidence as HRT but recommended psychotherapy over HRT?”
Making arguments like these ourselves isn't really helpful, since what we write has to be referenced from (and based upon the contents of) MEDRS sources anyway (without WP:SYNTH), regardless of our own personal beliefs and analysis.
we can’t neutrally say that the Cass Review was doing this for EBM
To be clear, I don't think that the review was commissioned solely or primarily to enable EBM or that this specific motivation (like, I believe, any other) existed in a vacuum. My sincere impression, at present, is that the Cass Review was commissioned in light of concerns raised (e.g. extensive waiting lists, a huge rise in referrals, and reports of inappropriate practice, including that not based upon evidence) in the GIDS. I believe it was intended to examine these reported issues and the existing evidence and then to make recommendations, based upon what they found and in accordance with evidence-based medicine, on how to improve the care given to TGGNC children and young people.
Per WP:VOICE, we shouldn't state a fact as an opinion. Therefore, if we can substantiate that the Cass Review was created to enable EBM as a fact with suitable references (even if it is one of multiple motivations), we should state it as a fact rather than as an opinion. To this end, I believe the following MEDRS sources substantiate it as a fact. Some refer more to the lack of evidence underlying existing clinical practice in GIDS or elsewhere, and some mention that this led to the Cass Review more explicitly.
  • pages 20 and 75-77 of the final report of the Cass Review
  • Cheung, C Ronny; Abbruzzese, Evgenia; Lockhart, Elaine; Maconochie, Ian K; Kingdon, Camilla C (14 October 2024). "Gender medicine and the Cass Review: why medicine and the law make poor bedfellows". Archives of Disease in Childhood: 2. doi:10.1136/archdischild-2024-327994.
  • Barnes, Hannah (8 March 2023). "Gender identity services in the UK are on pause as evidence comes under scrutiny". BMJ. 380: 509. doi:10.1136/bmj.p509.
  • McCartney, Margaret (30 May 2024). "Medical institutions must treat the Cass review as a significant event and act upon it". BMJ: 1. doi:10.1136/bmj.q1189. I know many senior medics who were concerned about the lack of evidence for interventions...
  • Evans, Marcus (October 2021). "Freedom to think: the need for thorough assessment and treatment of gender dysphoric children". BJPsych Bulletin. 45 (5): 286. doi:10.1192/bjb.2020.72.
  • Thompson, Lucy; Sarovic, Darko; Wilson, Philip; Irwin, Louis; Visnitchi, Dana; Sämfjord, Angela; Gillberg, Christopher (8 August 2023). "A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment". PLOS Global Public Health. 3 (8): 3. doi:10.1371/journal.pgph.0001478.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  • D'Angelo, Roberto (18 November 2023). "Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy". Journal of Medical Ethics: 1. doi:10.1136/jme-2023-109282.
Please get back to me and let me know what you think when you have time. Thanks! 13tez (talk) 15:46, 20 December 2024 (UTC)[reply]
  • The Cass Review is not an impartial source on itself
  • Cheung et al. is written by multiple people who are members of conversion therapy orgs or famous for pushing conversion therapy
  • Barnes did not say it was evidence based
  • McCartney is an opinion piece
  • Evans is a member of conversion therapy orgs, and unsurprisingly spends a few paragraphs in that article attacking the Memorandum of Understanding on Conversion Therapy (fringe to say the least)
  • Thomspon et al does not say Cass was motivated by EBM
  • D'Angelo is the head of a conversion therapy org, and that's a primary piece where he defends it, and where he doesn't say the Cass Review was motivated by EBM
Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:14, 20 December 2024 (UTC)[reply]
Hey, thanks for your thoughts!
The Cass Review is not an impartial source on itself
Earlier consensus here was that the final report itself does qualify as WP:MEDRS and that it's suitable to use as a reference in this article, including on itself.
Cheung et al. is written by multiple people who are members of conversion therapy orgs or famous for pushing conversion therapy
Regardless of any (potentially valid) reservations about an author, it was published in Archives of Disease in Childhood by the BMJ Group, so it is a valid MEDRS source.
Barnes did not say it was evidence based
I'm not providing sources to say the Cass Review was evidence-based, because that has already been established. These sources are intended to show that there was concern that current practice before the Cass Review wasn't sufficiently based on evidence, and, therefore, that the Cass Review was, in part, motivated by a desire to enable EBM for this patient cohort.
Barnes highlighted the concerns on insufficient evidence, among other issues, that led to the Cass Review: "Some GIDS staff began to worry. The service, they believed, did not adequately consider that the evidence base underpinning the medical treatment of young people—the so called Dutch protocol—not only was limited in and of itself but applied to a different group of young people from those largely seeking the help of GIDS."
McCartney is an opinion piece
I checked, and it wasn't externally peer-reviewed, so I take that point.
Evans is a member of conversion therapy orgs, and unsurprisingly spends a few paragraphs in that article attacking the Memorandum of Understanding on Conversion Therapy (fringe to say the least)
Regardless of any (potentially valid) reservations about an author, it was published in BJPsych Bulletin by Cambridge University Press, so it is a valid MEDRS source.
Thomspon et al does not say Cass was motivated by EBM
From page 3, as cited: "...illustrating the acknowledged lack of good quality evidence regarding treatment comorbidities and outcomes to inform service design. Concern in the UK led to the commissioning of the Cass review..."
D'Angelo is the head of a conversion therapy org, and that's a primary piece where he defends it, and where he doesn't say the Cass Review was motivated by EBM
Regardless of any (potentially valid) reservations about an author, it was published in the Journal of Medical Ethics by the BMJ Group, so it is a valid MEDRS source.
From page 1, as cited: "Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth...critics claim the poor-quality evidence base warrants extreme caution...The Royal Australian and New Zealand College of Psychiatrists (RANZCP) articulates the central controversy in Position Statement 103, namely that ‘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’. The recent Cass Review 2 and subsequent National Health Service (NHS) Interim Service Specification highlight the uncertainty about whether gender- affirming medical interventions or psychosocial and mental health interventions (including exploratory psychotherapy) are most helpful and safe for young people experiencing gender dysphoria."
Please let me know if you have any other thoughts. Thank you! 13tez (talk) 18:48, 20 December 2024 (UTC)[reply]
These quotes cannot possibly support the statement that the York reviews were commissioned to enable EBM, as the York reviews are not mentioned in them at all. Flounder fillet (talk) 11:51, 19 December 2024 (UTC)[reply]
From Thornton: "Cass commissioned four systematic reviews of the evidence on key issues, including puberty blockers, hormones, and clinical guidelines."
From the Cass Review's final report: "This lack of evidence placed limitations on the advice that could be given by the Review. An independent research programme was commissioned with the aim of providing the Review with the best available collation of published evidence, as well as qualitative and quantitative research to fill knowledge gaps. The research programme, led by the University of York, comprised appraisal of the published evidence and guidelines, an international survey and quantitative and qualitative research. A Clinical Expert Group (CEG) was established by the Review to help interpret the findings. This final report provides full details of the research approach and methodology used by the research team and a synthesis of the findings alongside interpretation of what they mean for the Review. The peer reviewed systematic reviews have been published alongside this report." 13tez (talk) 13:27, 19 December 2024 (UTC)[reply]
This in turn doesn't mention EBM. Flounder fillet (talk) 17:33, 19 December 2024 (UTC)[reply]
You said: "These quotes cannot possibly support the statement that the York reviews were commissioned to enable EBM, as the York reviews are not mentioned in them at all."
I was just showing you that this isn't true. The references from which the quotes are taken explicitly discuss the York systematic reviews. You can see this in the two new quotes from them I provided in my last reply to you.
Neither of the two pairs of quotes I have provided in this thread are the entirety of either of the two references from which they're taken. After all, one is the final report of the review itself. You are opining on whether the references discuss the reviews or EBM while assuming the quotes I am taking from them are the references in their entirety. This is not the case. 13tez (talk) 19:14, 19 December 2024 (UTC)[reply]
I wrote quotes, not citations. I was at no point "opining on whether the references discuss the reviews or EBM" - I was stating that the quotes you have chosen to include in your original post, the ones in quotation marks, are irrelevant to the statement you added to the page. Flounder fillet (talk) 19:39, 19 December 2024 (UTC)[reply]
You are correct in saying that the individual quotes I've provided in this thread don't discuss both EBM and the systematic reviews. However, the references from which they're taken contain more than just those quotes, and this isn't what I was arguing to begin with. 13tez (talk) 20:35, 19 December 2024 (UTC)[reply]
Well I've seen you added it to the motivating factors section now instead. Lewisguile (talk) 20:40, 19 December 2024 (UTC)[reply]
For clarity, I didn't add the enabling of EBM to the Motivating issues section. I only paraphrased those that are directly listed in page 77 of the review itself. I also qualified these factors by saying they're what the review listed as the key motivating issues. I don't think it would be appropriate to add enabling EBM there because it isn't included in this list from the review. 13tez (talk) 20:46, 19 December 2024 (UTC)[reply]
You probably shouldn't add so much text to an article while these issues are still being discussed. You've made a lot of changes, some of which are WP:POINTY and others which simply aren't well written. Because the edits are all done in small edits, I can't revert them partially to only remove the bad. I will have to revert them all, and you'll have to make your case for what you want to include here per WP:ONUS and WP:BRD. You can read about the enforced BRD process on this page here. Lewisguile (talk) 09:20, 20 December 2024 (UTC)[reply]

International reaction

Both the article lede, and the "Response from other health bodies globally" section, seem to give the impression that most health bodies outside the UK opposed the report's findings. But I would note that a number of medical authorities in various European countries, including Sweden, had already made changes to severely limit medical and surgical gender transitioning for minors in the years prior to this review's release. I did a quick search now, but haven't yet found any official reaction to the Cass Review from those countries' medical authorities. But it would be reasonable to surmise that bodies which disagree with the report would be more motivated to issue an official reaction, registering that disagreement, than those in agreement with it, so this could skew the sampling. In any case, I think it would be worth noting in the article that countries like Norway, Sweden, and Finland had already implemented most of the Cass Report's recommendations before it was published. -2003:CA:8728:D5C2:F3ED:8883:9187:C5E5 (talk) 21:10, 17 December 2024 (UTC)[reply]

I think it would be difficult to put in anything which isn’t explicitly related to the Cass Review. Those countries might well agree with many or most of the recommendations, but if they implemented them before the review was published, then they are probably not a significant fact about the review. This article shouldn’t become an index of everybody that agreed or disagreed with the report, and it especially shouldn’t become an index of everybody who merely acted concordantly with the report. Barnards.tar.gz (talk) 21:20, 17 December 2024 (UTC)[reply]
Re: "difficult to put in anything which isn’t explicitly related to the Cass Review"
The NYT article, which I've quoted an except of in another reply below, actually explicitly links the changes other European countries have made in recent years to Cass. [1]
-2003:CA:8728:D5C2:F3ED:8883:9187:C5E5 (talk) 22:46, 17 December 2024 (UTC)[reply]
So I read this article you linked, and I think it’s worth noting that it also makes a very strong point of connecting it to the larger right wing political shift, and that any sentence which mentions the trend citing this source, needs to include that as well for NPOV Snokalok (talk) 23:02, 18 December 2024 (UTC)[reply]
This is a proposal to hang a WP:COAT. These are different changes that were made for different reasons in different times and different places. See https://www.politico.com/news/2023/10/06/us-europe-transgender-care-00119106 for more information about the exact changes in Norway and Sweden. Flounder fillet (talk) 21:53, 17 December 2024 (UTC)[reply]
I would disagree with your WP:COAT argument, as it's normal to give some background and context when discussing a new report. This gives readers important information as to whether a given report and its recommendations are an isolated aberration, or part of a larger trend. Obviously trends in other European countries shouldn't be the main focus of the article, which would be in line with "COAT," but they can be mentioned to contextualize. Regarding the Politico article you linked, in particular, this article, while not specifically labeled as an op-ed or opinion piece, is clearly opinion-driven, spinning and arguing that the recent policy changes in many European countries aren't actually so significant....And of course there's nothing wrong with arguing that position, but Wiki's coverage should be more balanced. -2003:CA:8728:D5C2:F3ED:8883:9187:C5E5 (talk) 22:33, 17 December 2024 (UTC)[reply]
As a followup, I did a quick search now, and found several good articles which balance out the Politico article's spin: [2], [3], [4], and [5]. The last of those articles, from the NYT was actually published after the Cass Report came out, and explicitly links Cass with the larger trend, thus alleviating any possible "SYNTH" concerns:
"England’s move is part of a broader shift in northern Europe, where health officials have been concerned by soaring demand for adolescent gender treatments in recent years. Many patients also have mental health conditions that make it difficult to pinpoint the root cause of their distress, known as dysphoria.
In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases.”
In December, regional health authorities in Norway designated youth gender medicine as a “treatment under trial,” meaning hormones will be prescribed only to adolescents in clinical trials. And in Denmark, new guidelines being finalized this year will limit hormone treatments to transgender adolescents who have experienced dysphoria since early childhood."
-2003:CA:8728:D5C2:F3ED:8883:9187:C5E5 (talk) 22:43, 17 December 2024 (UTC)[reply]
No objection to something along the lines of "has been described as part of a trend of [sufficiently neutral broad descriptor here]". Flounder fillet (talk) 00:09, 18 December 2024 (UTC)[reply]
Same. Something neutral along those lines is fine. Lewisguile (talk) 15:59, 18 December 2024 (UTC)[reply]
Did this get added in? Lewisguile (talk) 16:21, 21 December 2024 (UTC)[reply]
no Flounder fillet (talk) 22:37, 22 December 2024 (UTC)[reply]
I think that this section will look better and be more encyclopedic a few years from now. We eventually want (and expect) to reach a point in which the article says something like "The recommendations around puberty blockers were supported by nearly all UK medical organizations and most northern European gender care organizations, as well as religious organizations and right-wing politicians. It was strongly opposed by multiple American-led gender care groups, who were concerned that a greater diversity in standards for gender care management in developed countries would lead to additionally politically motivated restrictions on gender care in the US. The recommendations about how many separate locations in England should offer gener care were a yawning bore that almost nobody in the UK actually cared about, and absolutely nobody outside the UK." We're just don't have the sources for that kind of general summary yet, and we probably won't until someone writes a book about it. WhatamIdoing (talk) 00:44, 19 December 2024 (UTC)[reply]
But that's extrapolating a lot from the sources so far provided. As for whether it's boring or not, Wikipedia is not WP:NOTAFORUM. Lewisguile (talk) 07:53, 19 December 2024 (UTC)[reply]
That's not even extrapolating from sources. I was making up hypothetical future article text based on hypothetical future sources. One of these days, probably years from now, I believe we'll be able to write a decent encyclopedic summary of the reaction. Earlier this year, we started with laundry lists and proselines about who said what when. We've progressed to thoughtfully curated laundry lists. But we are hampered by the non-existence of sources that take a high-level overview. WhatamIdoing (talk) 17:25, 19 December 2024 (UTC)[reply]
Fair enough. Such is the problem with covering "rolling news" (not quite rolling anymore, but you know what I mean). Lewisguile (talk) 20:39, 19 December 2024 (UTC)[reply]
Indeed. WhatamIdoing (talk) 03:23, 20 December 2024 (UTC)[reply]

Revert per enforced BRD

I've just reverted a series of edits by @13tez per the enforced WP:BRD on this page described here. I responded in the ongoing EBM thread to let the editor know, but am also adding it here so it's easier to find/see this for others.

Some of the edits are issues undergoing discussion at present, some make the article harder to read, and some seem a little pointed (e.g., the constant references to how systematic reviews are the best), so 13tez will need to get consensus for the changes here. Some may be fine; others may require more discussion.

13tez, it might be a good idea to start a new topic for each key area you want to make changes in, with suggested wording. That way, it won't get as bogged down. Thanks in advance! Lewisguile (talk) 09:28, 20 December 2024 (UTC)[reply]

Hi, thanks for letting me know.
Please can you tell me which portions of content I added you thought should (and should not) be removed before your revert and why?
Thanks! 13tez (talk) 09:47, 20 December 2024 (UTC)[reply]
As per WP:ONUS and WP:BRD, you should justify why the text is needed in the first place. There were a series of edits, so I don't have time to go through them all, but off the top of my head, there were a few typos, the language became slacker in certain areas, and the framing seemed non-neutral/editorialising. E.g., you mentioned "huge increases" ("huge" always seems emotive to me), gave a lot of space and added an image to stress the idea that systematic reviews are the best (this isn't needed beyond maybe a few extra words, since readers can click on the relevant article to find more), added tangential sources to support the same, added a new section which hasn't been discussed or received consensus, etc. I didn't go very far back, so it seemed this would revert the fewest number of overall edits and this makes it easier for me to self-revert if others think there's a consensus for the additions/changes. Lewisguile (talk) 10:51, 20 December 2024 (UTC)[reply]
Thanks for getting back to me. I'll try to discuss each of your concerns in order; please let me know if I've missed any of your points or if you still have any.
From what you've said, you don't seem to be opposed to how I edited RCPH for consistency or the paragraph beginning "The Royal Australian and New Zealand College of Psychiatrists rejected calls for...". Please can you tell me if I'm right in thinking you're not opposed to these changes?
per WP:ONUS and WP:BRD, you should justify why the text is needed in the first place
I think that the Motivating issues section is an important addition to the Background section because, without it, readers will not know which key issues resulted in the decision to commission the review. This would prevent them from fully understanding the background or context that led to the review being made. Describing this background and context to readers is the purpose of the Background section of the article.
I added an illustrative diagram of the hierarchy of evidence, showing systematic reviews, to give readers a visual understanding that each level of evidence in medical research feeds up into the one above it and that systematic reviews are considered the highest of these levels. Since the systematic reviews it commissioned are the foundation of the Cass Review, this helps readers understand the make-up and quality of the evidence that informed it. I added the information on the journal in which the systematic reviews were published and that they formed some (really most) of the evidence that informed the report and its findings. Again, this helps inform readers on the nature of the evidence and how it was used to develop the conclusions of the Cass Review. This information is relevant to the Methodology section of the article.
There were a series of edits, so I don't have time to go through them all
Per WP:BRD-NOT, if you're unable or unwilling to explain the substantive reasons for reverting edits, you cannot do so.
there were a few typos, the language became slacker in certain areas
I'd have been happy for you to have tightened up the language or fixed typos, or I'd be happy to do so now myself if you pointed out the issues. Notwithstanding other reservations, these small issues could have been addressed with a fix, and wouldn't necessitate the revert, per WP:BRDR. How do you think we should fix the copyedit issues?
the framing seemed non-neutral/editorialising. E.g., you mentioned "huge increases" ("huge" always seems emotive to me)
I'd be happy to discuss any issues in regarding editorialising because I wouldn't want to do so, but nobody's perfect. I think "huge" is an objectively true way to describe an increase of 3442.86%, and the review used the word "exponential" itself. However, if you'd prefer a less emotive adjective, I take that point and am open to suggestions. Maybe we could cite an exact figure to get away from adjectives altogether?
the constant references to how systematic reviews are the best...gave a lot of space and added an image to stress the idea that systematic reviews are the best
I don't think two references to the position of systematic reviews as the highest level of evidence in medical research can be accurately described as "constant". As I tried to describe in the summary of the edit where I implemented it, I made one in-text reference to this fact to host the references and the nuance of some hierarchies (there are multiple) also including meta-analyses in the top tier of evidence there. This allowed the caption of the image showing the pyramid illustrating the hierarchy of evidence to be simplified and and not need references. It also benefited text-only readers who might not read an image caption. Can you think of a better, alternative approach here?
I think the image helps readers understand the role of systematic reviews, and, in turn, the methodology of the Cass Review. I think it's a useful illustrative aid in this regard. The only space is this one image and another single sentence, so I don't think it's a disproportionately large amount of coverage considering it's within the Methodology section of the article and the importance of the systematic reviews to the Cass Review's methodology. Do you think that the use of the image falls within MOS:IMAGES?
added tangential sources to support the same
What makes you think the sources are tangential? One was the Cass Review itself; one was published in Hospital Pediatrics, a journal of the American Academy of Pediatrics; and one was published in Evidence-Based Medicine, a journal of the BMJ. They were all relevant to the specific point, saying:
  • "The highest form of evidence is that generated by a systematic review"
  • "The quality of evidence from medical research is partially deemed by the hierarchy of study designs. On the lowest level, the hierarchy of study designs begins with animal and translational studies and expert opinion, and then ascends to descriptive case reports or case series, followed by analytic observational designs such as cohort studies, then randomized controlled trials, and finally systematic reviews and meta-analyses as the highest quality evidence."
  • "A pyramid has expressed the idea of hierarchy of medical evidence for so long, that not all evidence is the same. Systematic reviews and meta-analyses have been placed at the top of this pyramid for several good reasons."
added a new section which hasn't been discussed or received consensus
Per WP:BOLD and WP:BRD, you don't need permission to make new edits. If something is under discussion or disputed, you can't unilaterally add it, but I never added what was being discussed: whether enabling EBM was a motivation for holding the Cass Review.
Please get back to me when you have time. Thanks! 13tez (talk) 13:07, 20 December 2024 (UTC)[reply]
Thanks for your quick reply! I'm ill with COVID, so bear with me if I don't check here immediately. I also appreciate your edits are in good faith, so I just want to get that out of the way.
Per WP:BRD-NOT, if you're unable or unwilling to explain the substantive reasons for reverting edits, you cannot do so. I did try to explain the main issues, re: NPOV (editorialising, pointiness) and lack of consensus, though in brief. I also explained that as you made multiple smaller edits, I couldn't just revert some parts without doing it manually for each one. But I'll go into a bit more detail below.
Even if material is verifiable, it doesn't necessarily mean it's notable or that it should be included. We have to make sure that what's included is WP:DUE and has consensus for inclusion. Neutrality can be affected by what is put into an article and what is left out, which means that using lots of detail in particular areas can reinforce the idea that this area is being emphasised. We should also keep it easy to read and stick to what's relevant.
In regards to the "systematic reviews" part, besides the issues I had mentioned already, you rearranged the paragraph to put that statement first, which seemed to emphasize that part. You also expanded the section on the York reviews to say where they were published, who the publisher was, its official affiliations and that it was peer-reviewed (which read, at least to me, like appeals to authority). Most of this isn't needed, as people can see who the reviewers are by following the references and clicking the relevant blue links. They can see who the publisher is. Describing all of this stuff at length can feel like the prose is trying to convince us of something, whether intended or not.
The motivating issues section also repeats much of the same information as the Methodology section, albeit in different wording and framing. It's largely redundant on that basis, and again, in the context of all the above, it reads as WP:POINTY.
All of this could've been trimmed for overegging the pudding anyway, and for adding extraneous detail, but the series of edits with these changes, plus the image, caption and repetition of the caption in the article body, do not appear to be WP:NPOV. In fact, the cumulative effect is like the article is trying to tell us a particular viewpoint. (I appreciate that it's easy to get swept up in detail that's interesting to us as editors without realising how it can make things seem lopsided.)
Of course, all of this is subjective, which is why I think we need to get more eyes on this. If others agree to keep the edits, I am always happy to self-revert if someone pings me. I'm also happy to workshop the text, although I may need to leave the detailed stuff till tomorrow since my attention is currently all over the place. Lewisguile (talk) 14:09, 20 December 2024 (UTC)[reply]
Tossing in my agreement with everything you said. Snokalok (talk) 14:47, 20 December 2024 (UTC)[reply]
It's possible that both of you need to read WP:POINTY again, since it is about Malicious compliance and Work-to-rule efforts, in which an editor disagrees with a rule and wants to screw up articles or processes by proving that following the rule can have unwanted effects. Don't rely on the name of the WP:UPPERCASE. A pointed statement (one that sharply [over]emphasizes a point) is not a WP:POINTY edit. WhatamIdoing (talk) 21:16, 20 December 2024 (UTC)[reply]
Totally my fault! Sorry about that! Lewisguile (talk) 12:58, 21 December 2024 (UTC)[reply]
(An aside: the page you mean is probably WP:TENDENTIOUS, which covers editing that is argumentative or biased.) Loki (talk) 20:52, 21 December 2024 (UTC)[reply]
I think the pyramid image is helpful. This kind of pyramid diagram is included in the report itself (p55), and it really speaks to the heart of the matter. Barnards.tar.gz (talk) 15:00, 20 December 2024 (UTC)[reply]
Thanks for getting back to me again, and sorry to hear you have covid; I hope you get better soon.
To know where we now stand on your previous concerns after trying to allay them, please can you tell me:
  • If you understand the rationale for the edits I made to "RCPH" through the article for consistency and the paragraph beginning "The Royal Australian and New Zealand College of Psychiatrists rejected calls for...", and if you agree that they are suitable?
  • If you understand my rationale for including the pyramid hierarchy of evidence image and if you think it is useful for readers and falls within MOS:IMAGES?
  • If you still view the references substantiating that systematic reviews are the highest level of evidence in medical research as being tangential?
I also appreciate your edits are in good faith, so I just want to get that out of the way.
Thank you, I feel the same.
Even if material is verifiable, it doesn't necessarily mean it's notable or that it should be included.
I explained why I think my additions were due when justifying their additions in my last reply. Did you disagree with what I had to say?
you rearranged the paragraph to put that statement first, which seemed to emphasize that part
In all honesty, the reason why I made the paragraph breaks is simply because the single paragraph was getting too long. I think (?) you're saying that one of the new paragraphs started with the information that systematic reviews are the highest level of evidence to highlight it. However, that sentence came at the end of the first paragraph.
You also expanded the section on the York reviews to say where they were published, who the publisher was, its official affiliations and that it was peer-reviewed (which read, at least to me, like appeals to authority)...Describing all of this stuff at length can feel like the prose is trying to convince us of something, whether intended or not.
I don't see how it could be an appeal to authority when it isn't making an argument. If it went on to argue something based on an appeal to the authority of those who made the systematic reviews, it would be, but it doesn't. To some extent, MEDRS in a way works by appealing to authority anyway. Regardless, again, I think this information is due in the Methodology section, which exists to outline the methodology underlying the Cass Review, which was largely based upon the systematic reviews.
Do you think rephrasing this information somehow or even siloing it in a subsection, which people could skip if they're not interested in the particulars of the systematic reviews, could help this issue that it feels like an argument to you? How do you think we should resolve the issue of you feeling like my text is editorialising generally? Should we re-write it, e.g. with "huge" as we discussed before?
Most of this isn't needed, as people can see who the reviewers are by following the references and clicking the relevant blue links. They can see who the publisher is.
We could equally argue readers could go and read the references to see how the systematic reviews worked, what they discussed, etc. By this logic, lots of the content within the Methodology section (and the article as a whole) would be removed. The result would be that readers would be less informed. Can you understand why I don't see this as a good way to decide which content to include?
The motivating issues section also repeats much of the same information as the Methodology section...It's largely redundant on that basis
I really wouldn't have thought you'd think so. To be clear, do you mean the list of the "topics covered by the systematic reviews" in the Methodology section was too similar to the Motivating issues?
To me, the Motivating issues are the concerns which led to the review being commissioned, e.g. huge increases in referrals, intolerable waiting lists, unexplained drastic changes in the patient cohort, etc. To be neutral, I gave the caveat that the list was from and per the final report of the review. Conversely, the topics covered in the systematic reviews examine clinical practice caring for those patients, looking at things like puberty blockers, gender-affirming hormone therapy, psychosocial support, etc.
In short, I think the Motivating issues were concerns that caused the report to be created vs topics related to different areas of clinical practice assessed by the systematic reviews. I think the two are distinct enough to not be redundant. Do you still think including both is redundant?
I'm also happy to workshop the text
I'm very happy for my changes to be included while being rewritten more elegantly and simply, and I'm happy for copyedit issues to be fixed with or without me. How do you think this should be done?
I hope you feel better soon; please let me know what your thoughts are when you can! 13tez (talk) 18:13, 20 December 2024 (UTC)[reply]
About people can see who the reviewers are by following the references and clicking the relevant blue links:
Research indicates that most readers/non-editors will follow one reference about 1 out of 300 page views, and they will click on one or two links on desktop (either to get to this article, or to leave it for another), and zero or one link on mobile (about 65% of all readers) in an entire session. The Wikipedia rabbit hole behavior is uncommon.
For this article in particular, looking at last month's numbers, only 15% of readers click on a link to read another Wikipedia articles. So we should be writing the article, to use the wording from Wikipedia:The perfect article, to be "self-contained", because 85% of readers are not clicking through to any other articles, and >99% of readers are not clicking through to any refs.
In case you are curious, about 65% of readers last month came from Google/outside of Wikipedia. 8% last month came from our article on Kemi Badenoch (it was 1.5% the month before, so something must have happened in the news), 3% from Hilary Cass (5% the month before), and around 2.5% from Political views of J. K. Rowling.
85% of readers here stop after this article. Less than 5% of page views result in someone going to Hilary Cass, which is about 30% of the (small number of) readers who click on anything. Around 1% go to Bell v Tavistock and Time to Think (book), and everything else is tiny (less than 1% of page views/less than three readers per day). WhatamIdoing (talk) 22:08, 20 December 2024 (UTC)[reply]
Thanks for your patience, @13tez. I'm feeling a fair bit better at the moment — nighttimes are the killer because it's hard to breathe. I've gone ahead and reincorporated some of your edits with tweaks to make them, I feel, more balanced. There's one or two I haven't made yet, as I wanted tour input. I'll go through these in detail below:
  • The Royal Australian and New Zealand College of Psychiatrists rejected calls for an inquiry into trans healthcare following the release of the Cass Review, characterising it as one review among several in the field. They emphasised that, "assessment and treatment should be patient centred, evidence-informed and responsive to and supportive of the child or young person's needs and that psychiatrists have a responsibility to counter stigma and discrimination directed towards trans and gender diverse people." This wording seems fine to me. I restored it as it was.
  • Linking the RCPCH and adding the abbreviation afterwards is also fine. I have gone ahead and made that specific change for you.
  • The refs to systematic reviews being the highest quality of evidence were as follows:
Neither of these seem relevant to the Cass Review, unless I'm missing something, so I feel like we're possibly veering into WP:COATRACK territory. This isn't an article about the use of systematic reviews. What's important is what the use of systematic reviews means for the Cass Review, not what they mean in general. Though I suppose we can use these refs if we end up adding an endnote for this (see further down).
  • The image of the pyramid shouldn't be considered on its own but in conjunction with the other material added about systematic reviews. Whether people are likely to click through to a systematic review article or not is irrelevant; that's their choice. One reason for not clicking through might be that they already know what something is, for instance. But either way, a standalone article needs to introduce the concepts in sufficient detail to make them clear in the context of this subject, but no more, because those concepts aren't the main focus of this article. On that basis, I don't think the image is WP:DUE, because it's taking up space and word count for one detail. That detail can be added in other ways so it's less of a tangent. See below.
  • This wording is clunky and is trying to do too much in general (even before your additions): The Cass Review commissioned several peer-reviewed, independent systematic reviews into different areas of healthcare for children and young people with gender identity issues, including gender dysphoria. Systematic reviews, sometimes along with meta-analyses, are generally considered the highest level of evidence in medical research.
  • I think this is a better compromise: The Cass Review commissioned several independent systematic reviews into different areas of healthcare for children and young people accessing gender identity services in the UK. Would you be happy if we made this change? "Independent" isn't strictly needed, since we say in the next bit that the reviews were done by the University of York, but it's not a hill I'm willing to die on, so I've left it in.
  • I would leave "peer reviewed" with the publication info, like so: The systematic reviews were published in Archives of Disease in Childhood, the peer-reviewed medical journal of the Royal College of Paediatrics and Child Health. Otherwise, you have "peer-reviewed, independent systematic reviews", which is really clunky. This way, we avoid repeating the same information in multiple places, and the same wording in the same sentence. This also avoids repeating that the reviews were used to inform the Cass Report, since this is also stated in the line beginning The systematic reviews performed meta-analyses... (Though this line was also clunky, so I rejigged it.)
  • If anything else needs to go in here, I'd suggest an endnote, such as: [a] This is where we could use your refs about the value of systematic reviews.
  • I don't see how it could be an appeal to authority when it isn't making an argument. I think the wording, as it was, did read like it was making an argument, for all the reasons I outlined above (emphasis, etc). Besides, per WP:INCITE, there's very rarely a need to include detailed attribution in this way; a specific reason stated for that policy is that people can click on the reference to find out more (regardless of whether they actually do or not). The wording I've suggested here, I think, is hopefully a fairer compromise and more concise.
  • To be clear, do you mean the list of the "topics covered by the systematic reviews" in the Methodology section was too similar to the Motivating issues? I do, in that the topics covered necessarily imply they were things being looked for, if that makes sense? However, I've suggested alternate wording that doesn't require another short sections within a short section: Key concerns which led to the creation of the review included increasing waiting lists due to larger numbers of children and young people requesting gender-affirming care from the NHS (over two years per patient), proportionally fewer patients who were assigned male at birth (AMAB) and an increasing number who were assigned female at birth (AFAB), a reported trend towards earlier medical interventions in this cohort, and concerns around the quality of evidence for treatment in this area.
What do you think of these suggestions in general? I think we've kept the main thrust of what you wanted to add, while keeping it all proportionate to what else is in there. If there's anything I've still missed (darn brain fog!), please let me know. Lewisguile (talk) 12:50, 21 December 2024 (UTC)[reply]
@Snokalok, what do you think about the above? Lewisguile (talk) 13:23, 21 December 2024 (UTC)[reply]
I’d change the “key concerns” bit, since as it’s currently worded it imo gives too much validity to some of the stated concerns. I’d reframe it as “stated concerns” instead. I believe it should change“medical interventions” to “medical treatment”. More neutral.
Past that, I think if we emphasize that the York reviews are peer reviewed systematic reviews, we need to make clear that the Cass Review *isn’t* any of those things, it’s just the opinion resulting from someone having read those reviews.
Those are my two main things. The first is a minor tweak that I’m going to BEBOLD on, the second we might need to workshop more thoroughly. Snokalok (talk) 16:04, 21 December 2024 (UTC)[reply]
Thanks. I support both those wording changes for neutrality. Good catch.
I also support your other suggestions, re: peer review, for the reasons you state. At the moment, the language might lead readers to assume the Cass Review itself is peer-reviewed. Though, I think that since the Methodology section now clearly states "peer-reviewed" in relation to the publication of the systematic reviews, I think it's definitely better than it was. I have also stated where another journal was peer reviewed for balance. Lewisguile (talk) 16:15, 21 December 2024 (UTC)[reply]
Hi @Snokalok, please can you undo your revert of my recent edit? Your stated reason was: "Removing excess info about publication, since per talk it was only agreed upon as being relevant if contrasted with the fact that the Cass Review is not peer-reviewed, as to avoid an appeal to authority"
However, my edit did not add any information. It only removed information, adjusted language, and rearranged text, for the reasons I explained in the edit summary. Thanks! 13tez (talk) 19:50, 21 December 2024 (UTC)[reply]
Ah! Yes, easy confusion. The text discussing the journal it was published in and that journal’s pedigree was boldly added earlier (which I personally disagree with doing but whatever) before consensus was obtained, and then solidified with the agreement above that it was only worth keeping if we contrasted it with the fact that the Cass Review is not peer reviewed and instead only built itself off other pubs, which I thought was made obvious in the report itself. However given that we can’t agree yet on the latter it seems, we shouldn’t have the former either - otherwise it creates the earlier issue stated by Lewis of reading as an appeal to authority. Snokalok (talk) 19:59, 21 December 2024 (UTC)[reply]
My bad! I thought my text wouldn't be controversial. Snokalok, what if we added the peer review clarification as an endnote? Would you settle for that? It might seem less objectionable to others if it's done like that instead? Lewisguile (talk) 20:27, 21 December 2024 (UTC)[reply]
I think that that’s giving it too much weight one way. If we had both the archives of disease in childhood AND the not peer reviewed thing in endnotes then fine, but otherwise it feels like we’re just trotting out a list of titles the Cass Review doesn’t actually hold, like medals given to North Korean generals. It gives the implication that the Cass Review was peer reviewed by the archives of disease in childhood, which it wasn’t. Snokalok (talk) 20:39, 21 December 2024 (UTC)[reply]
Sorry, @Snokalok, I didn't read my replies in order. It's a valid point. Hmmm. I'm not sure. On principle, I'm not opposed to saying where the reviews were published, but it's definitely not essential information and it's about as important as clarifying whether the Cass Review itself was peer reviewed. I think the RS for saying the Cass Review wasn't peer reviewed itself is the Cass Review? Nowhere does it state her recommendations and conclusions were peer reviewed – indeed, she says the opposite: that it was independent, and wasn't seen in advance by the NHS and Government. She details her process. If she didn't say the final report was peer reviewed, then it wasn't.Lewisguile (talk) 19:20, 22 December 2024 (UTC)[reply]
Hey @Snokalok, thanks for getting back to me! Sorry for my mistake - I originally thought your edit was just a revert of my edit, but it actually removed information Lewisguile added in an attempt to form a compromise.
I removed the information that the Cass Review was not peer-reviewed primarily because it was not referenced. The references placed at the end of that sentence were actually references for the previous sentence - that AODIC is the journal of the RCPCH. Their presence there was erroneous. However, that single sentence by itself, at the end of a paragraph otherwise discussing the systematic reviews, doesn't seem especially relevant.
I understand you think that if we say the systematic reviews were peer-reviewed, we need to say the Cass Review itself wasn't for balance. However, the latter was not referenced; this situation was already the status quo even before my originally contested edits; both Lewisguile and I were fine with it: this was the case in the changes they made and I agreed to; and the fact that the systematic reviews underwent a peer-review process is relevant to the methodology section because they were the foundation of the evidence upon which the Cass Review made its conclusions.
It gives the implication that the Cass Review was peer reviewed by the archives of disease in childhood, which it wasn’t.
How so? It's saying the systematic reviews commissioned by the Cass Review were peer-reviewed and published there, not the Cass Review itself.
Thanks! 13tez (talk) 21:03, 21 December 2024 (UTC)[reply]
So regarding citation, a small error on my part - I’d made the assumption that one of the citations was a direct Cass Report citation since, they’re everywhere, but it wasn’t and that was a mistake on my end.
Past that, as you can see above Lewis agreed with my take on the matter that there needed to be balancing via saying Cass is not peer reviewed.
As for your question, because the reader is very severely liable to see the words “Cass Review” and that it commissioned several systematic reviews, and come to the conclusion of the Cass Review just being the culmination of those and thus warranting the same prestige and pedigree as the peer reviewed pubs when in reality, the Cass Review is not that - it’s a non-peer reviewed government report that makes significant leaps in logic and conclusions not supported by the underlying systematic reviews (such as transness being caused by porn), and if we don’t make the distance between the two clear, a reader is very easily liable to mistake the statements of the Cass Review for the conclusions of the York Review, hence why we need to emphasize the difference or else not risk misattributing the authority. Snokalok (talk) 23:26, 21 December 2024 (UTC)[reply]
Once again, it's not a government report. Void if removed (talk) 23:48, 21 December 2024 (UTC)[reply]
The NHS is a government entity. An NHS report without peer review is therefore nothing more than a government report Snokalok (talk) 04:07, 22 December 2024 (UTC)[reply]
Hi @Snokalok, thanks for getting back to me again!
as you can see above Lewis agreed with my take on the matter that there needed to be balancing via saying Cass is not peer reviewed
However, they edited to the contrary, notwithstanding my other reasons for retaining the longstanding situation of the systematic reviews being described as peer-reviewed (which you alone have overridden) described previously and the views of other editors.
a reader is very easily liable to mistake the statements of the Cass Review for the conclusions of the York Review
Even though the latter did inform and lead to the former, I think we might find common ground here. I was thinking of adding a table summarising the results of the different systematic reviews, for example with the following columns:
  • intervention (e.g. puberty blockers)
  • number of relevant studies found
  • number of low quality studies
  • number of moderate quality studies
  • number of high quality studies
  • the strength of evidence overall (e.g. very low, low... very high)
  • the ability to make conclusions on the merits and effects of the intervention (e.g. very low, low... very high)
Please can you tell me what you'd think of adding something like this to the article?
Thanks! 13tez (talk) 00:18, 22 December 2024 (UTC)[reply]
So let me start by answering your first point regarding Lewis:
Thanks. I support both those wording changes for neutrality. Good catch.
I also support your other suggestions, re: peer review, for the reasons you state. At the moment, the language might lead readers to assume the Cass Review itself is peer-reviewed. Answered by Lewis in regards to me adding that Cass is not peer reviewed. Diff provided. [6]
With that out of the way, yes the York Reviews informed them but they didn’t lead to the Cass Review, merely fed it. Again repeating my example, nowhere in the York Reviews did they say transness was caused by pornography, and yet the Cass Review did. Thus, we have to keep them separate, because the Cass Review draws conclusions not drawn in nor supported by the York Reviews, and to treat them as synonymous or as direct representations of each other would be facile.
As for your proposed table, I personally like the bar graph image you already added, I think that does a better job of conveying the info you want. Snokalok (talk) 04:13, 22 December 2024 (UTC)[reply]
Hey @Snokalok, thanks for getting back to me again!
So let me start by answering...Diff provided.
Again though: they edited to the contrary; the sentence saying the Cass Review was not peer-reviewed was not referenced; the status quo even before my originally contested edits was saying the SRs were peer-reviewed without saying the Cass Review wasn't, and one or even two editors cannot override that, especially while it's contentious; both Lewisguile and I were fine with it: this was the case in what they suggested and the changes they made and I agreed to; the fact that the systematic reviews underwent a peer-review process is relevant to the methodology section because they were the foundation of the evidence upon which the Cass Review made its conclusions; and the views of other editors weren't considered when you removed the fact that the systematic reviews were peer-reviewed.
yes the York Reviews informed them but they didn’t lead to the Cass Review, merely fed it
What do you mean by "lead" - leading to the creation of the review itself or leading to its findings? If you read the Cass Review, they definitely did lead to its findings.
the Cass Review draws conclusions not drawn in nor supported by the York Reviews
This isn't true. Apart from already being able to reference it from MEDRS sources, you can see in the final report for yourself how the findings of the systematic reviews are referenced, discussed, and used to create the findings and recommendations of the report. For example:
nowhere in the York Reviews did they say transness was caused by pornography, and yet the Cass Review did
How did you come to that understanding? Did it come from you reading the final report yourself? Did it come from you reading a discussion of it from a third party?
If you read the Cass Review, it discusses the effect of pornography on children on page 110. All it really says on the matter is:
  • more children are exposed to pornography from a young age
  • "Several longitudinal studies have found that adolescent pornography consumption is associated with subsequent increased sexual, relational and body dissatisfaction (Hanson,2020)"
  • "Research commentators recommend more investigation into consumption of online pornography and gender dysphoria is needed. Some researchers (Nadrowski, 2023) suggest that exploration with gender-questioning youth should include consideration of their engagement with pornographic content."
What it says is objectively true. It doesn't make any claims or assertions on the effects of pornography on TGGNC young people, let alone the one you're claiming it made: "transness was caused by pornography". It recommends more research to understand any potential effects of pornography on gender-questioning youth, which doesn't necessarily mean a causal relationship whatsoever.
I personally like the bar graph image you already added
OK, glad we can agree on that.
Please let me know what you think when you can! 13tez (talk) 13:08, 22 December 2024 (UTC)[reply]
Both LewisGuile and I were fine with it Yes and then when I stated my reasons to Lewis, he changed his mind, as the diff I provided above shows. He is no longer in agreement with you.
Regarding pornography, the report still suggests it as a cause of transness, and however you wish to characterize its claims, it still makes them without the York reviews doing anything of the sort. Thus, it’s a statement made entirely separately, and thus we can’t treat Cass and York as the same. Snokalok (talk) 13:23, 22 December 2024 (UTC)[reply]
Thanks for getting back to me again!
Yes and then when I stated my reasons to Lewis, he changed his mind, as the diff I provided above shows. He is no longer in agreement with you.
Again, firstly, that's not addressing any of my other reasons not to overturn the status quo of saying the SRs were peer-reviewed without saying the Cass Review wasn't. Secondly, we can just discuss it with them, let them speak for themselves, and form a compromise, like we've been trying to do.
Regarding pornography, the report still suggests it as a cause of transness
No it doesn't. Which quote from the final report, in your view, substantiates that claim? I showed you the direct quotes from the page in the report that discusses the effects of pornography. It doesn't make any claims or assertions on the effects of pornography on TGGNC young people, let alone the one you're claiming it made: "transness was caused by pornography". How did you come to that understanding? Did it come from you reading the final report yourself? Did it come from you reading a discussion of it from a third party?
we can’t treat Cass and York as the same
I'm not seeking this. I just wanted to say the systematic reviews were peer-reviewed and where they were published, and that they formed the bulk of the evidence which informed the final report of the Cass Review and its findings, because this information is relevant in the methodology section and all of these points are objectively true.
Thanks again! 13tez (talk) 13:38, 22 December 2024 (UTC)[reply]
Thanks for getting back to me again, @Lewisguile!
I'm feeling a fair bit better at the moment — nighttimes are the killer because it's hard to breathe.
I hope you continue to get better! Having had covid myself, I know exactly what you mean.
The Royal Australian...This wording seems fine to me. I restored it as it was....Linking the RCPCH and adding the abbreviation afterwards is also fine
Thanks!
I think this is a better compromise: "The Cass Review commissioned several independent systematic reviews into different areas of healthcare for children and young people accessing gender identity services in the UK." Would you be happy if we made this change?...I would leave "peer reviewed" with the publication info, like so: "The systematic reviews were published in Archives of Disease in Childhood, the peer-reviewed medical journal of the Royal College of Paediatrics and Child Health."
Yeah, I'm happy with that. I can live without the sentence on them being the highest level of research. I don't mind the omission of peer-reviewed in the first sentence, so long as we include that they were published in aodic and that it is peer-reviewed later on.
If anything else needs to go in here, I'd suggest an endnote, such as: This is where we could use your refs about the value of systematic reviews.
Yeah, that's actually a good idea. Would you be ok with having the information on systematic reviews being the highest level of evidence in an endnote like that? It could be a couple of sentences to inform the reader as to what a systematic review is, why they're good evidence/were used, etc?
I do, in that the topics covered necessarily imply they were things being looked for, if that makes sense?
Fair enough, I honestly see the two as distinct, so I didn't anticipate it as a potential issue at all.
I've suggested alternate wording that doesn't require another short sections within a short section: Key concerns which led to the creation of the review included
Thanks for compromising! I would say I think it was more readable as a bulleted list and I did qualify it by saying those were the key issues the report listed (albeit on a single page which can't go too in-depth) as the key motivating issues. Even though the rise in referrals and other concerns have been documented and are objectively true, I feel like it's also useful to say they're what the report itself says were the key issues.
What do you think of these suggestions in general?
Comparing my originally reverted edit to the current one, I'd make the following points:
On the Background section:
  • I'd say that the "stated concerns" were sourced from the review
  • I'd move "over two years per patient" to immediately after "waiting lists" to make the link more clear
  • We can omit the point re the change from mostly AMAB to mostly AFAB since it's shown in the graph and hard to explain in short form
  • I wouldn't say it was a "reported trend" since it objectively did happen and "trend" seems a bit deriding and unobjective (I know it was my original wording, but it was something I was planning on changing anyway)
On the Methodology section:
  • I (and Barnards.tar.gz) thought the pyramid image was helpful to understand the point of the systematic reviews. How would you feel about including the image with a similar caption, so long as we don't discuss it in the text as well?
  • The information on where the systematic reviews were published (the journal and the fact it's peer-reviewed) has now been removed. I feel like this is useful for the methodology section and removes the way in which we compromised on the matter. There is now no reference to the systematic reviews being peer-reviewed, even though this detail was already present even before my reverted edits and its definite relevance in the methodology section.
  • We are now excluding the information that the systematic reviews formed some (re MEDRS "the foundation") of the evidence for the findings of the Cass Review. Given its relevance in the methodology section, please can we restore this information?
  • Can we frame the last paragraph as objective truth? We're saying "the report says it did x" regarding other types of evidence it gathered. However, the consensus here was already that the final report itself is a MEDRS source, including on itself, and, realistically, we will also be able to find other MEDRS sources to substantiate these facts anyway. Per WP:VOICE, we should "avoid stating opinions as facts."
Miscellaneous:
  • Can we restore the external link to the GIDS series? I feel like it was useful.
Thanks again, hope you keep getting better! 13tez (talk) 20:39, 21 December 2024 (UTC)[reply]
Sorry for the late reply. I've been sleeping in an upright position this time to make breathing easier, and that's been working for me. I'm not so foggy-headed now.
Let me mull over your suggestions today and see if I can come up with some ideas that will also work for the others. I was quite happy with where things were yesterday, but I know a few people had issues with some of the wording since and we have, as a result, lost some of the wording I'd added as a compromise (as you noted).
I think we should be careful to avoid suggesting that the Cass Review was itself peer reviewed, rather than that it drew on peer reviewed sources (the systematic reviews). I think the picture gives the impression that the Cass Review itself is equivalent to the systematic reviews. I think a better image would be one which shows the relationship of the Cass Review to the published literature, grey literature, original research, and public engagement workshops. Does such an image exist? I'll re-read the reports today to see if I can find anything.
I think we can get to a consensus soon, but it is probably worth us tagging everyone currently active on the page, so we can make sure someone doesn't come along and undo any edits we've agreed upon here? Maybe I can start new threads for the Background and Methodology sections, so we can discuss the wording on them in their entirety in one dedicated place each? Individual tweaks that rely on other edits get lost when people start reverting or editing part of the text on isolation. Lewisguile (talk) 08:44, 22 December 2024 (UTC)[reply]
Hey @Lewisguile,
Sorry for the late reply. I've been sleeping in an upright position this time to make breathing easier, and that's been working for me. I'm not so foggy-headed now.
No problem! Take your time to get better!
we have...lost some of the wording I'd added as a compromise (as you noted).I think we should be careful to avoid suggesting that the Cass Review was itself peer reviewed, rather than that it drew on peer reviewed sources (the systematic reviews)
I'm yet to see a MEDRS source which can substantiate that the Cass Review itself wasn't peer-reviewed, so we still can't include it in the article. We could combine two of the sentences I made previously which might add the balance you want, something like: "The systematic reviews, which made up much of the evidence that informed the findings and conclusions of the Cass Review, were published in Archives of Disease in Childhood, a peer-reviewed medical journal..." This is more clearly saying that the systematic reviews were published in a peer-review journal and that they were some (per MEDRS "the foundation") of the evidence that informed the Cass Review, without suggesting the Cass Review itself was peer-reviewed. What do you think of that approach?
a better image would be one which shows the relationship of the Cass Review to the published literature, grey literature, original research, and public engagement workshops. Does such an image exist?
An illustrative image of the evidence base of the Cass Review can be found on pages 23 and 52 of the final report. I was thinking of making something similar and adding it to the methodology section myself to illustrate how the review gathered evidence then used it to inform its findings.
Maybe I can start new threads for the Background and Methodology sections, so we can discuss the wording on them in their entirety in one dedicated place each?
That's probably a good idea. I think we're almost there with the background section, so it doesn't make sense to conflate it with the discussions on the methodology section.
I think we can get to a consensus soon, but it is probably worth us tagging everyone currently active on the page, so we can make sure someone doesn't come along and undo any edits we've agreed upon here?
Yeah, that might be a good idea as well.
Hope you feel better soon! 13tez (talk) 13:20, 22 December 2024 (UTC)[reply]
Apologies again for the delay. I was feeling better, but then I took a heavy dip after lunch. I'm so sorry, because I feel like I've opened a can of worms and now can't deal with it as promptly as I normally would. Usually, I'm pretty good at getting back to people and offering suggestions. (Look at the November 2024 Amsterdam riots for an example – I'm obviously drawn to contentious topics!)
I want to dive into editing the Methodology and Background sections with you and @Snokalok, but I just don't think I can do it today.
Re: the image on p.24, I think that one's suitable (or obviously one like it which we can use).
I'll quickly offer my thoughts on this: The systematic reviews, which made up much of the evidence that informed the findings and conclusions of the Cass Review, were published in Archives of Disease in Childhood, a peer-reviewed medical journal...
Bearing in mind that Snokalok wants all this as an endnote, including the bit about the Cass Review not being peer reviewed, how about this tweaked version: The systematic reviews were used alongside [the things as show in the image based on the one on p.24] to inform the conclusions of the Cass Review. I don't want to say made up much of the evidence if Cass doesn't say that. From her intro and pages before and after the image on p.24, she states that she made her decisions based on the evidence she had available at the time, which doesn't specify any ratio or which evidence was given priority. She also says she drew her own conclusions based on that evidence, so she's interpreting things as she sees appropriate. She refers to the systematic reviews throughout, but she also refers to other forms of evidence. My experience of being involved in similar processes is that the systematic reviews inform a process of discussion and decision-making, but the committee (in this case, it may just be Cass on her own; I admit I don't know as much as some others here do) can decide whatever they think is justified, using all the available sources to explain it. Sometimes you lean more or less on the reviews, and clinical judgment and committed decision can count for a lot.
Is there any consensus among other experts on the ratio? Either way, for endnotes, I usually use {{efn|Text here.<ref name="x" /><ref name="y" />}}, which would look like this: [b] (using two random citations from the article). ETA: Adjusted this based on Snokalok's reply upthread which I missed.
  1. ^ Cite error: The named reference TheChair was invoked but never defined (see the help page).
  2. ^ Cite error: The named reference NHSCommissioning was invoked but never defined (see the help page).

Lewisguile (talk) 18:58, 22 December 2024 (UTC)[reply]

Methodology

@Lewisguile I have reverted the following edit.

This is the part for describing the report's methodology, neutrally, based on the best sources. Void if removed (talk) 13:50, 21 December 2024 (UTC)[reply]

Thanks, I saw that. I do think criticism of the processes is valid for the methodology section, and hiving it off only to the Responses section ends up risking non-neutrality. However, I am happy to add it to the Responses section for now and if anyone else feels strongly that it should also go in Methodology, we can return to that then.
As you specifically mentioned the complaints about trans non-inclusion/the governance group, I assumed you didn't have any problems with the wording changes re the description of meta-analysis? The wording there was awkward and didn't appear to be sourced on the page listed of the Cass Review (p. 4 is the title page), so I have replaced it with (a paraphrase of) the description used in the glossary on page 243, and changed the page in the reference too. If I've missed something there, let me know. Lewisguile (talk) 14:03, 21 December 2024 (UTC)[reply]
The Horton response has been discussed to death here and was excluded as an individual response in a compromise. It's also a response to the Interim review and not appropriate for the responses to the review itself. Void if removed (talk) 15:23, 21 December 2024 (UTC)[reply]
Do you have a link to the prior discussion showing consensus? I'm happy to self-revert if needed. Lewisguile (talk) 15:28, 21 December 2024 (UTC)[reply]
Never mind. Think I've found the discussion re: TOR. I'll go back in and remove it. Lewisguile (talk) 15:47, 21 December 2024 (UTC)[reply]

Interventions

@Snokalok you have changed "interventions" to "treatments" WRT the systematic reviews, tagged as a minor change. These reviews all say "interventions". This change is not warranted, and not minor. Treatment implies a positive act of care, intervention is neutral, and this wording is both preferable and accurate as relates to the sources. Void if removed (talk) 18:28, 21 December 2024 (UTC)[reply]

I disagree entirely. Yes, the sources say interventions, but intervention is not a neutral word, treatment is. Think:
”NSAID intervention” severe, foreboding
”NSAID treatment” neutral, ambiguous
”electroshock intervention” severe (and rightly so)
“Electroshock treatment” still appropriately severe but only because of the word electroshock, the word treatment is doing no lifting there.
”intervention” is a word with a negative connotation. Treatment is neutral, it doesn’t convey a positive connotation (as seen by electroshock) Snokalok (talk) 19:30, 21 December 2024 (UTC)[reply]
It's standard terminology. It's also what the sources use. Void if removed (talk) 20:02, 21 December 2024 (UTC)[reply]
Treatment is standard terminology, and the source is not neutral. We have an entire section of medorgs being very loud about that fact. And as wiki editors, it’s our duty when a source is not neutral to state its relevant info in neutral terms. Treatment is better than intervention Snokalok (talk) 20:04, 21 December 2024 (UTC)[reply]
I'm sorry, I just want to be clear: are you calling the systematic reviews "not neutral"? Void if removed (talk) 20:59, 21 December 2024 (UTC)[reply]
Treatment is probably not a POV word. A treatment doesn't have to work, or be appropriate. Intervention can be neutral in med-sci circles but for the general reader it can be particularly negative because of its associations with "having an intervention". Maybe it's worth asking over at the relevant MOS article? There may be a policy somewhere that's appropriate to guide us. Lewisguile (talk) 20:23, 21 December 2024 (UTC)[reply]
It has the same connotation as “medicalize”. While technically not an inapt description, it has the connotation of invasion. See also “military intervention”, “admin intervention”. Snokalok (talk) 20:26, 21 December 2024 (UTC)[reply]
Intervention has no such connotation. This is completely standard neutral terminology in a medical research context and adding your own subjective interpretation in order to justify deviating from the language used by the sources is completely unnecessary. The section you changed lists the titles of the reviews which are neutral and self-explanatory. Trying to justify it because you think these MEDRS aren't neutral is way off. Void if removed (talk) 21:14, 21 December 2024 (UTC)[reply]
There's nothing in MOS, but our WP article on Medical treatment (actually a redirect to Therapy; Treatment is a disambiguation page) says "care" is the broadest term, "intervention" is the narrowest (meaning an individual use of a treatment, such as taking your morning tablet), and "treatment" sits in the middle. So does this fit with how Cass uses the terms?
Looking at the Cass Review itself, it uses "intervention" 289 times and "treatment" 464. That includes referencing, which suggests the consensus among experts other than Cass herself also rests on using "treatment". She also seems to use "medical treatment(s)" and "medical intervention(s)" interchangeably, as she does with "hormone treatment(s)" and "hormone intervention(s)".
It's worth bearing in mind that everyday language is always useful for an encyclopaedia, since we aren't a medical science journal and our readers aren't (just) scientists or medics. When you look at another (also controversial) medical topic, Myalgic encephalomyelitis/chronic fatigue syndrome, that also avoids using some of the scientific and medical jargon for natural language. This is despite consensus for particular terms existing in the literature.
On balance, I think "treatment" wins out based on common usage, Cass' specific usage, its clarity, and its balance of breadth versus narrowness (it covers both general treatment approaches and individual instances of those approaches being applied, which I think is congruent with what Cass means when she says "intervention (s)"). However, I accept Void if removed's assertion that "intervention" is specifically used in that particular part of the Cass Review. A happy compromise might be to use "intervention" in direct quotes, so we're attributing it to Cass, and "treatment" when using Wikivoice. How do we all feel about that? It may involve some rewording, but it seems fair. Lewisguile (talk) 09:39, 22 December 2024 (UTC)[reply]

Was the Cass Review peer reviewed?

Nothing in the article seems to address this question unless I'm overlooking it. Nosferattus (talk) 19:43, 22 December 2024 (UTC)[reply]

We are currently discussing this. Per Cass' own description of the process, she only mentions the systematic reviews being peer reviewed. The whole point of the independent review is that she gets to make her own conclusions based on that evidence. Because she hasn't documented that the review was peer reviewed, I think it's pretty clear that it isn't (and she doesn't pretend that it is). But I'm sure there are people who feel very strongly that we can't include that in the article unless it's explicitly written somewhere. I'm not sure that follows (she included the protocols, process, etc; if it's not in those, it didn't happen), but, well, it's still an ongoing discussion. Lewisguile (talk) 19:55, 22 December 2024 (UTC)[reply]
WP:V will say that we can't include that in the article unless we have a reliable source that WP:Directly supports such a statement. And if none exist, then one has to wonder whether such a statement would be WP:DUE anyway.
About the above comments on the "peer-reviewed journal": Although that is a common phrase, it is somewhat more accurate to describe individual articles as being peer reviewed, because not everything in a peer-reviewed journal always undergoes (external) peer review. WhatamIdoing (talk) 07:06, 23 December 2024 (UTC)[reply]
I think you've got things reversed here. We can't describe the report itself as peer-reviewed if we can't verify that it was. What it appears to be is an administrative summary of peer-reviewed research. We should avoid using terms that imply that the report itself is peer-reviewed, as well: specifically, we should be very clear about what was in the reviews versus what was in the report summarizing those reviews. Loki (talk) 04:04, 25 December 2024 (UTC)[reply]
I agree. We can neither describe the final report as a peer-reviewed report, nor describe it as non-peer-reviewed report, unless we have sources.
My preference is to describe the systematic reviews as being peer-reviewed articles, and to describe nothing else (not the reports issued by Cass, not the journal in which the reviews appeared) in that language. WhatamIdoing (talk) 17:28, 25 December 2024 (UTC)[reply]
I'm fine with all of the above. I think we're in agreement. Lewisguile (talk) 17:43, 26 December 2024 (UTC)[reply]

Extensive changes

@Lewisguile going through your recent series of changes, re: this edit https://en.wikipedia.org/w/index.php?title=Cass_Review&diff=prev&oldid=1265397808&diffonly=1

This was accurate and not misleading. The issue is the citation referred to page 5, when it should be page 5 of Appendix 2 of the report. I ask you to reinstate the old text and fix the citation. Void if removed (talk) 21:14, 26 December 2024 (UTC)[reply]

Thanks for catching that re: the citation. I've just checked that page now (p. 273 in the Final Report), and it says: There is very little information about detail or type of psychological care received by children and/or adolescents under the care of a specialist gender service, and there is limited low quality evidence on the outcomes of psychosocial interventions for children and adolescents with gender dysphoria or incongruence. Most analyses of mental health, psychological and/or psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects. Only three studies assessed interventions that were specifically designed for children and/or adolescents experiencing gender incongruence, but these interventions varied considerably in content and delivery. I think the reason Cass didn't include this in the main report is because they were low quality findings, and hence weren't up to scratch.
Instead, Cass says (p. 30): The systematic review of psychosocial interventions found that the low quality of the studies, the poor reporting of the intervention details, and the wide variation in the types of interventions investigated, meant it was not possible to determine how effective different interventions were for children and young people experiencing gender distress.
So that's the takeaway. She couldn't make any conclusions due to low quality evidence. Including details of the low-quality results is likely WP:UNDUE and suggests we should do the same for other low quality outcomes. In this case, after confirming the text is in the appendix, I still think it shouldn't be in there. Lewisguile (talk) 22:33, 26 December 2024 (UTC)[reply]

Updates and copyedits

I have gone through the article to make some general copyedits for length and repetition, and to add page refs to some of the citations (see diffs here – moving stuff up has made some edits look larger in markup). I have tried to keep the meaning the same. In a few instances, I have removed text that was either apparently unsourced or which didn't reflect the source material (see thread immediately above this one). Where I could, I simply reworded such text, and only removed it when it wasn't there at all in the sources or was unclear/misleading. I'm noting here a few of my own queries/things we might still want to consider:

  • There are conflicting views about the clinical approach, with expectation at times being far from usual clinical practice. This has made some clinicians fearful of working with gender-questioning young people, despite their presentation being similar to many children and young people presenting to other NHS services. We previously said clinicians had expectations far from the norm based on this, but I think this is actually talking about the expectations of service users and their families. I.e., that the expectation among patients and their families that they will/should receive treatment x, and that clinicians who don't offer this worry they'll suffer sanctions or face a complaint. That was a strong theme in the York papers, and makes sense in the context. If I'm reading that wrong, I'm happy to restore that wording or an alternative, as needed.
  • In-keeping with the general consensus for orgs over individuals in the Responses section (which is still really long), I have trimmed or removed statements by, e.g., the president or chair of an organisation if their comments were substantively the same as those of their org. E.g., if the org says "Yes!" and they say "Yay!" I've left quotes that add extra/different info ("Yay, but..." or "No").
  • On responses in general, the length is partly to due with lots of direct quotes. We could probably round up some of the Responses (in the format of orgs x, y and z supported the review but x said "something else" as well). In the meantime, I have trimmed the direct quotes a bit, both for length and to avoid extensive reproduction of text from sources. I don't believe these have changed the meaning of any quotes, but please ping me if I've left something important out or misinterpreted anything.
  • I think the Methodology section spends too much time on the independent systematic reviews, rather than the Cass Review process itself. This may need some workshopping.
  • Do we need a terminology or "concepts" section? There are some concepts that are overlapping and the nuances may not immediately be clear to readers (e.g., gender dysphoria, gender incongruence, gender-related distress). We can outline how the systematic reviews and Cass Review use these terms, if there are differences.
  • I added one sentence to summary Cass' response at the end of the lede: Following high profile media coverage, Cass expressed concern that misinformation about the review had spread online and elsewhere, and that her review was being weaponised against trans people. It seems important to mention both of these things. This wording seems fairly neutral to me and hopefully conveys the points in broad strokes, without needing to go into too much detail here. Hopefully this isn't controversial, but as always, I am happy to self-revert if necessary.

Thoughts are always welcome. Lewisguile (talk) 10:44, 27 December 2024 (UTC)[reply]

I agree with your idea of summarizing responses, and suggest that it should be "orgs x, y and z supported the review, and x said "something else" as well". One risk is that the supporters may be easy to summarize, which could result in "A, B, C, D, E, F, G, H, I, J, K, L, M, O, N, P, Q, R, S, T, U, V, W, and X all supported the review, but Y said <multiple sentences of disagreement> and Z said <long paragraph of disagreement>", which would amount to providing UNDUE weight to a minority of organizations.
Right now, we have a long list of subsections, to which I have added a quick guess at the overall 'feel' of the contents:
  • Response from UK political parties and public bodies: 90% support
  • Response from devolved governments: 80% support
  • Response from health bodies in the United Kingdom: 90% support
  • Response from other health bodies globally: 10% support
  • Response from transgender specialist medical bodies: 0% support
  • Other academic responses: 20% support
  • Reception by charities and human rights organisations: 40% support
  • Reception by gender-critical organisations: 100% support
The thing about summarizing is that the high levels of support are fairly boring: A, B, C, D, etc., all basically support the review and its recommendations. The opponents, however, are all over the map: N disagrees about this specific thing. O disagrees about a different specific thing. P throws out an ad hominem attack on Cass herself. Q makes an (unsubstantiated?) claim that Bad People were involved. R thinks it's fine, as long as it doesn't get imported into R's country. And so forth. The net result for the reader is that a concise summary of (for example) 60% support could look like 90% opposition, merely because the opposition can't be summarized as simply. WhatamIdoing (talk) 21:39, 27 December 2024 (UTC)[reply]
I hear you. But one way around that is to cluster them by the groupings we currently have. So "political parties x, y and z said this", "medical groups a, b and c said that", and so on. If we workshop the text here we might be able to pare it down fairly while making sure it doesn't feel unbalanced? We did something similar for November 2024 Amsterdam riots and it worked quite well. That section was equally long and got pared right back. Lewisguile (talk) 07:56, 28 December 2024 (UTC)[reply]
I'll take a stab at a draft tomorrow and post it here. I think we can do it without unbalancing things. I think we can keep it balanced through the space we give to each side. Lewisguile (talk) 18:42, 28 December 2024 (UTC)[reply]

Interim report issues

Some more concerns (hopefully addressed) in the "Interim report" section:

  • While GIDS initially followed the Dutch protocol Technically, the interim report says it was "based on" and "paralleled" the Dutch protocol. It seems to have been somewhat different from the beginning, so I've clarified this. The report also says most px don't get referred for endocrine tx, so we should clarify that for balance. However, it does so while also saying there was insufficient data when referrals were made. I've attempted to address all these things here: The report said that while most children referred to GIDS did not receive endocrine treatment, there was insufficient detail provided about their broader needs when they did.[1] The report also said that the current NHS approach to hormone interventions had "significant differences" from the Dutch protocol on which it was initially based.[2] For example, the report said there were no clear guidelines for when to provide psychological support before or instead of medical treatment, endocrinologists administering puberty blockers did not attend multidisciplinary meetings, and there was insufficient capacity to increase (or even maintain) appointments once adolescents received puberty blockers.[3]. I also pushed this to a new paragraph for ease of reading, and began with "The report said..." to avoid opening with "While..." per MOS:EDITORIAL. You'll also note I tweaked the bit about psych comorbidities here, since the page referenced (p. 18) is actually talking about the lack of screening for psych issues before or instead of hormone tx (which is more directly related to the topic at hand). I've reworded on that basis.
  • Another quibble: the bit about GPs under pressure was combined with a later comment about diagnostic overshadowing from another point that wasn't directly connected. This gave the impression that the overshadowing was due to pressure to affirm, whereas the report itself doesn't make that connection. (In context, it seems to be saying things are missed because of the tertiary care model, which skips local services.) I've reworded this so they're clearly separate thoughts and the context is clearer.The interim report said GPs and other non-GIDS staff felt "under pressure to adopt an unquestioning affirmative approach" to children unsure of their gender. The report also said that diagnosis of gender-related distress sometimes led to "diagnostic overshadowing", where comorbidities such as poor mental health – which were usually managed by local services – were overlooked.[4]
  • Immediately following this, I've added some of the reasons for why the report thinks this is happening: The report suggested that long wait times to access GIDS had resulted in increased distress for patients and their families, as well as less time for exploration – since patients arrived having already begun social transition and with expectations of a rapid assessment process.[5]
  • This is immediately followed by the Tavistock response as before, but I added In response... to clarify.
  • Other than that, I added a couple of words for flow so it all hangs together.

Again, if I've missed anything, or if you think this has unbalanced things a bit, do let me know. This section was originally almost entirely negative, whereas Cass herself was more nuanced. Hopefully this shows that. Lewisguile (talk) 12:49, 28 December 2024 (UTC)[reply]

Following on from this, I think the order should be tweaked a little for this section. Such as:
  • Current intro (up to lack of data collection)
  • GPs felt... up to rapid assessment process. (Move Tavi response down.)
  • Endocrine tx and Dutch protocol para here. Move up "gaps in the evidence" bit here (add ref) and move down NICE/NHS bit.
  • NICE/NHS England response here (maybe its own paragraph)
  • Sajid Javid response, Tavistock response (change "In response..." to "In response to the interim report..."), WPATH and associates response.
What do you think? That seems more coherent to me and flows better. Lewisguile (talk) 13:04, 28 December 2024 (UTC)[reply]
It seems to have been somewhat different from the beginning
Do you have a source for this? That's not at all my understanding and p70 of the Cass Review says the opposite, ie that GIDS initial trial was in line with the Dutch Protocol.
It was the model endorsed by Spack in the US in 2007 that deviated, and the pressure from eg. parent groups to adopt this model in GIDS after the early intervention study has started that caused divergence. Void if removed (talk) 13:52, 28 December 2024 (UTC)[reply]
Also you're inappropriately indicating social transition was a result of long wait times.
This is not the case, and indeed if you look at the York reviews is a global trend independent of wait time. Void if removed (talk) 13:57, 28 December 2024 (UTC)[reply]
Are you reading the interim report? Re: the Dutch protocol, Cass says: Although GIDS initially reported its approach to early endocrine intervention as being based on the Dutch Approach, there are significant differences in the NHS approach. (p. 18, Interim Report) and: From 2011, early administration of puberty blockers was started in England under a research protocol, which partially paralleled the Dutch Approach (the Early Intervention Study). From 2014, this protocol [i.e., the research protocol] was adopted by GIDS as routine clinical practice. (p. 31, Interim Report)
I take your point about the change in approach, so what about the following: The report said that while the initial GIDS approach to hormone interventions "partially paralleled" the Dutch protocol... That is a bit clunky, but more accurate. Instead of the direct quote, we could also just say partially based on.
Re: social transition, Cass says: From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision (p. 17, Interim Report). So she specifically says the delay is a cause. Remember this is about the interim conclusions, not the final report. Lewisguile (talk) 14:46, 28 December 2024 (UTC)[reply]
That says the *extent* of social transition, not that social transition is a result of long waiting times. The point being made is that parents and children/young people enter the system with expectations that have cemented due to long wait times. This is quite different. It isn't a matter of long wait times leading to social transition, it is that long wait times exacerbate an existing situation. Void if removed (talk) 16:54, 28 December 2024 (UTC)[reply]
The current article text doesn't say social transition is due to a long waiting time (at least not intentionally). It currently says: The report suggested that long wait times to access GIDS had resulted in increased distress for patients and their families, as well as less time for exploration – since patients arrived having already begun social transition and with expectations of a rapid assessment process. I.e., they can't explore social transition when they reach the clinic because it's already well underway.
However, if you think that this suggests that social transition wouldn't have occurred at all if there weren't wait lists, then that certainly wasn't my intent, and we should change it. How would you reword it? Perhaps since patients arrived having already progressed with social transition? Or since patients were relatively far along with their social transitions? Maybe the latter is better? Lewisguile (talk) 17:43, 28 December 2024 (UTC)[reply]

References

  1. ^ Cass review interim report 2022, p. 40.
  2. ^ Cass review interim report 2022, p. 18, 31.
  3. ^ Cass review interim report 2022, p. 18.
  4. ^ Cass review interim report 2022, p. 17.
  5. ^ Cass review interim report 2022, pp. 17, 19.


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