Talk:Gender dysphoria/Archive 6

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We should remove the second sentence: "People with gender dysphoria are typically transgender."

Conflating gender dysphoria with being transgendered is incorrect.

Saying gender dysphoric people are "typically transgendered" ignores the lived experiences of those who are gender fluid, gender queer, non-binary, or have gender dysphoria but don't transition. Further more, for the vast majority of pre-adolescent children exhibit symptoms of gender dysphoria, their symptoms abate over the course of puberty without their transitioning. Finally, a small number of gender dysphoric people transition and then de-transition.

In the broad picture, it is likely that only a minority of all people who have gender dysphoria are also transgender.

MorrisGretsky (talk) 01:07, 26 October 2020 (UTC)

“Conflating gender dysphoria with being transgendered is incorrect.” The article isn’t saying that. We aren’t saying that being Transgender and having gender dysphoria is the same. However, a lot of trans people have gender dysphoria so they are heavily connected.

“ignores the lived experiences of those who are gender fluid, gender queer, non-binary“

Those kind of people can have gender dysphoria too. Many health organizations know this.

“In the broad picture, it is likely that only a minority of all people who have gender dysphoria are also transgender.”

Do you have sources for that? CycoMa (talk) 03:12, 26 October 2020 (UTC)

(edit conflict) "Incorrect" based on what? Your personal theories about what is "likely", won't cause any changes to the article, but statements backed by citations in reliable sources might. If you have any concrete improvements to the article to propose, this page is the place to do it. Mathglot (talk) 03:22, 26 October 2020 (UTC)

MorrisGretsky, I think you're confusing the words "transgender" and "transexual". People who are gender fluid, gender queer, and non-binary are normally considered transgender. Kaldari (talk) 22:01, 1 December 2020 (UTC)

Regarding this, this, this and this? The lead sentence of the Transgender article states, "Transgender people have a gender identity or gender expression that differs from the sex that they were assigned at birth." The lead sentence of the Gender dysphoria article states, "Gender dysphoria (GD) is the distress a person feels due to a mismatch between their gender identity and their sex assigned at birth." This 2017 "DSM-5® and Family Systems" source, from Springer Publishing Company, page 352, that I added to the lead, states, "People meeting criteria for Gender Dysphoria most often identify themselves as trans or transgender. Trans or transgender can be used as umbrella terms to include the broad spectrum of persons whose gender identity differs from the assigned gender (APA, 2013)." So when it comes to MorrisGretsky's above argument and Maneesh having added that Zucker source that I removed from the lead, I ask, "In what way are we doubting that most people with gender dysphoria are transgender?" Let's discount prepubescent children -- a group that usually ceases to feel like the opposite sex by or during puberty...but were considered transgender (by some sources) for a time. Is the argument that most people who have experienced gender dysphoria are cisgender? Are we saying this because a lot of gender-nonconforming people experience gender dysphoria and gender-nonconforming people in general are more prevalent than the specific group of gender-nonconforming people who are also transgender? If so, I don't see sources stating that most people with gender dysphoria are cisgender. But I do have access to sources (like the one I cited in this paragraph) stating that those with gender dysphoria are typically, or most often identify as, transgender. Sure, sources also note that not all transgender people experience gender dysphoria or that their gender dysphoria may be relieved by hormone therapy and also maybe by surgery, but sources still attribute gender dysphoria to mainly being a transgender thing, and also as a diagnosis to help treat the distress transgender and gender-nonconforming people feel with regard to their assigned sex. The Zucker piece can be included lower in the article with accurate wording, but I don't see that it belongs in the lead. Not until we work out the best way to relay it in the lead. Flyer22 Frozen (talk) 00:35, 4 December 2020 (UTC) Tweaked post. Flyer22 Frozen (talk) 00:48, 4 December 2020 (UTC)

The claim in the Family Systems source seem quite glib and not backed up with anything credible in terms of evidence. Transgender-identification is, as best as I can tell, an identity; anyone can claim it. The following assertions have easily verified sources: Gender dysphoria is not a requirement for trans-identification, the prevalence of transgender-identification is difficult to assess and there is no terribly compelling estimate, we are stuck with clinically referred cases to assess gender dysphoria. Childhood gender dysphoria does EDIT: not have a clear relationship to trans-identification given children may not be exposed to the idea of trans-identification (certainly true outside english speaking countries). The stability of the identification is also an open question. Keep all these facts in mind, this article should be very careful about implying the link the between transgender-identification and gender dysphoria. A diagnosis of gender dysphoria is (generally) a requirement to undergo procedures like surgery/hormones etc. (at least in western countries, homosexuality will sign you up for those procedures in Iran) so there is a clear link to transexuals only. Maneesh (talk) 23:43, 5 December 2020 (UTC)

We follow what the sources state. So while I haven't looked into this edit you made, if the source states that, it states that. As for the "DSM-5® and Family Systems" source? One of the listed authors of the book is Jason H. King, PhD, CMHC. And the listing states that he is "a core faculty member and student development coordinator, School of Counseling Programs, Walden University. [He] owned and clinically directed an outpatient mental health and substance abuse treatment clinic that collected data for the American Psychiatric Association's Routine Clinical Practice field trials that informed the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) revision process. Because of this role he is listed on page 914 of the DSM-5 as a Collaborating Investigator. He served as a DSM-5 Revision Task Force committee member for the American Mental Health Counselors Association (AMHCA) and ACA and has given over 190 national and international trainings on the DSM-5 since its publication in May 2013." The listing also tells us that he is "the DSM-5 specialist for the PIMSY Electronic Health Record (EHR) practice management mental/behavioral health advisory board" and "is the DSM-5 content editor for the textbook Diagnosing Children and Adolescents: Guide for Mental Health Practitioners."

Like I noted above, this source is not the only one to state what it does about the identities of those with gender dypshoria or the group that the gender dysphoria diagnosis is mainly for. I'm not going to list other sources just to prove my point on this. Stating that people meeting the criteria for gender dysphoria most often identify themselves as trans or transgender is not a controversial statement. And we all know that, like the source states, trans or transgender are umbrella terms including the broad spectrum of persons whose gender identity differs from the assigned gender. The first three sources (sources I added years back) in the lead sentence of the Transgender article tell us that. What it takes to be diagnosed with gender dysphoria is in the Diagnosis section. Flyer22 Frozen (talk) 19:57, 6 December 2020 (UTC)

How would you expect young children with gender dysphoria to identify themselves as trans? How is that not a controversial statement?Maneesh (talk) 20:09, 6 December 2020 (UTC)

I think I was clear when I stated, "Let's discount prepubescent children -- a group that usually ceases to feel like the opposite sex by or during puberty...but were considered transgender (by some sources) for a time." The source states "identify themselves as." Many young children these days identify as trans. We already know that the significant majority of them will cease to have gender dysphoria and therefore cease to identify as trans. Whether they are counted or not, the source is speaking of those with gender dysphoria. And sources report that those who have gender dysphoria throughout puberty will very likely continue to be gender dysphoric and have a trans identity. Regardless, it's not up to us to debate sources or the overall literature; we are to follow it, not lead it. Flyer22 Frozen (talk) 20:26, 6 December 2020 (UTC)

You are conflating things. People can identify as trans without any requirements other than to be exposed to to English and cultures from certain countries (to have access to the western/european notion of 'trans'). A young child in China or North Korea or many other parts of the world with gender dysphoria would be unlikely to identify as 'trans'. Gender dysphoria is not limited to english speaking people. You are equating the very thing in question when you say 'We already know that the significant majority of them will cease to have gender dysphoria and therefore cease to identify as trans'. Maneesh (talk) 23:16, 6 December 2020 (UTC)

This is just speculation. I don't see a need for a change since what we have is supported by reliable sources, and we don't do anything besides go by what they say. Crossroads ^-talk- 04:40, 7 December 2020 (UTC)

Not speculation at all, it's just basic facts. How could someone who only spoke no English identify as transgender? Look at the Zucker article that *focuses* on trying to understanding the disparity in between the number of transgender identifying people and the number of people that show up in the clinic for GD. The explanation he comes up with is essentially that we don't know and more research is needed. Furthermore you'll find plenty of sources from intersex advocacy organizations that explicitly tell you that intersex and transgender are not the same thing, yet GD in intersex people is (understandably) something that is studied closely. Not all people who identify as transgender have/had GD, not all people who have/had GD identify/identified as transgender; simple facts. Equating transgender identifying people with people who have gender dysphoria is quite silly. The only link you can really come to is that in many countries (not all) GD diagnosis is a requirement to undergo SRS procedures. Maneesh (talk) 05:02, 7 December 2020 (UTC)

Okay, but commonly (or typically) people with GD do identify as transgender, according to sources. Some with GD don't identify as trans, but that correlation is strong enough to mention. Crossroads ^-talk- 05:26, 7 December 2020 (UTC)

This is a page about a clinical condition which means you need something that looks like a proper prevalence estimate before you say something about a clinical population. That source is nothing but a glib equivocation. Zucker's paper looks at that claim much more carefully and does not support it. Maneesh (talk) 06:23, 7 December 2020 (UTC)

Gender dysphoria is not a condition limited to a clinical population. Studies often clarify that they are examining "clinically significant gender dysphoria" to differentiate from the large pool of transgender people who experience GD but do not seek medical intervention. Regardless, the wording has been changed to "commonly identify", so it seems like this is a moot point now. Kaldari (talk) 16:27, 7 December 2020 (UTC)

I wasn't conflating anything, Maneesh. Flyer22 Frozen (talk) 21:37, 7 December 2020 (UTC)

"We already know that the significant majority of them will cease to have gender dysphoria and therefore cease to identify as trans." the article was corrected by me a few days ago to reflect what the source says (and what obviously makes more sense) to"Follow-up studies of children with gender dysphoria consistently show that the majority of them will not remain gender dysphoric". Clinical papers are typically very careful about what they are saying and don't mix gender dysphoria and trans-identification glibly. Maneesh (talk) 18:24, 8 December 2020 (UTC)

I did not mix up anything. This matter was explained to you very clearly by three editors above. If you want to keep insisting that I and/or others are confused and that we should neglect what the sources state and only go by the Zucker source, your interpretation of the Zucker source, and/or your speculations, then you can. But we have made our comments on this, and there is no need to keep debating you. Flyer22 Frozen (talk) 22:48, 8 December 2020 (UTC)

Now you are implying that it is only Zucker that adheres to the distinction between transgender-identification and the clinical condition of gender dysphoria. It's quite common (and obviously important) amongst high quality clinical source We use “transgender” to refer to self-identified population samples and “gender dysphoria” to refer to those who present clinical symptoms., "Not all transgender people suffer from gender dysphoria and that distinction is important to keep in mind. Gender dysphoria and/or coming out as transgender can occur at any age." etc. Maneesh (talk) 00:05, 9 December 2020 (UTC)

You are stating things that I did not state or imply. And you are not listening. I'm done replying to you on this. Flyer22 Frozen (talk) 01:02, 9 December 2020 (UTC)

Content about Tavistock and Portman NHS Foundation Trust clinic

Three of the five paragraphs of the "Biological treatments" section are specifically about the Tavistock and Portman NHS Foundation Trust clinic's use of puberty-blocking drugs. Here are all the problems with that:

• Devoting half of the section to discussion of a single clinic and its research is clearly WP:UNDUE. In comparison, the section only mentions hormone therapy in passing in a single sentence.
• The wording about T&P seems to be rather promotional. It reads like it was added by T&P's PR agency.
• Material about puberty-blocking belongs in the "Prepubescent children" section, not the "Biological treatments" section. It's confusing to discuss it in 2 separate places.
• Discussion of a single court ruling from this month (that has yet to be appealed) is WP:RECENTISM.
• Discussion of a single clinical trial violates WP:PRIMARY, WP:MEDRS, and WP:UNDUE.
• Why does it include a mini-debate and pricing information about a single puberty-blocking drug, Gonapeptyl? There are lots of different puberty-blocking drugs. Concentrating on the specific one used by the T&P clinic is WP:UNDUE and promotional.
• The content is specific to the UK and does not reflect a world-wide point of view.

All 3 paragraphs should be deleted IMO. Kaldari (talk) 22:21, 1 December 2020 (UTC)

I certainly agree with some of this. Some of the writing on the T&P in that section really isn't neutral. There is an odd asymmetry in that the positive tone stood for a long time and the moment there has been some news counter to that narrative, it is all being removed. The Bell case is widely reported and does have a significant impact on the treatment of gender dysphoria in young people in the UK and in other countries. In fact I'm pretty sure it was brought up just today in a meeting for Bill C-6 in Canada. The court case like this has to happen somewhere so I can't say I buy world-wide point of view, will all prominent legal cases about things not be reported since so many significant things don't affect the whole world immediately? I think there should be a sentence or so about the only on most recent decision that talks about the 'unlikely' ability to consent to puberty blocker and the limited evidence of puberty blockers. Maneesh (talk) 04:49, 2 December 2020 (UTC)

I removed the content that focused specifically on the T&P clinic and moved the remaining material related to puberty blocking in the UK to the "Prepubescent children" section. I still think the remaining content is too UK specific and too news-like. The court decision is going to be appealed according to the T&P, so it is unclear whether it will even have a lasting effect in the UK (much less other countries). Every country has its own regulations about the use of puberty blockers and its own related drama and court cases. It would be ridiculous for us to try to present them all here, and the UK shouldn't have the stage all to itself. This is textbook systemic bias and WP:UNDUE. I think the remaining paragraph should be deleted as well (or at least moved to Gender dysphoria in children). What are other folks opinions? Kaldari (talk) 02:03, 4 December 2020 (UTC)

I'm concerned that Kaldari is pushing a viewpoint: "I still think the remaining content is too UK specific and too news-like. The court decision is going to be appealed according to the T&P, so it is unclear whether it will even have a lasting effect in the UK (much less other countries)." which seems to place the cart before the horse. The Bell case is notable because of its global precedence, as noted here above by editor Maneesh... The institution of this talk page section on 2 December, and the brevity of the comment period (2 days) before Kaldari's removal of text lends weight to the claim of partiality. Additionally, Kaldari obtained scarce support for the change (only one editor) before it was made... Kaldari disregards the fact that "prepubescent children" were not at issue in the T&P section. Magnovvig (talk) 11:06, 4 December 2020 (UTC)

@Magnovvig: And exactly what viewpoint am I pushing? I laid out my concerns clearly above, most of which you have ignored. The only part you responded to is about the court case, which in case you didn't notice, I left in the article. Do you have any response to my concerns about the rest of the content, which I laid out above? If we leave the UK-specific content, we also need to include the puberty blocking legal controversies currently happening across the U.S.—most recently in Missouri, Florida, Illinois, Oklahoma, Colorado, South Carolina, Kentucky, South Dakota, Georgia, and Texas. And if we did that, the article would quickly be 90% about puberty blocking legal controversies. This content would be much more appropriate at puberty blocker or gender dysphoria in children (or perhaps new articles like puberty blocking in the United Kingdom or Legal status of puberty blocking). It is completely WP:UNDUE here. The UK is not the center of the universe. Kaldari (talk) 17:20, 4 December 2020 (UTC)

Magnovvig, you need to stop WP:Edit warring over this. The content is excessive and should be trimmed. And like I indicated with this edit, you added the material under the "Management" heading. The "Management" section should be in line with WP:MEDSECTIONS, but the content you added has all that legal material in it. We should consider moving it to the "Society and culture" section. It doesn't need its own heading, though. All it needs is a single paragraph. And that excessive material is not needed at the Gender dysphoria in children article either; I would revert if it was added there. That article already has sufficient material on the matter. Flyer22 Frozen (talk) 00:39, 5 December 2020 (UTC) Added to post. Flyer22 Frozen (talk) 00:48, 5 December 2020 (UTC)

The definition of WP:Edit warring is quite clear and I have been scrupulous to observe it. Please don't start a controversy where there is none, @Flyer22 Frozen:. Magnovvig (talk) 08:53, 5 December 2020 (UTC)

Magnovvig, slow edit warring is still edit warring. Editors can be reported and blocked for slow edit warring. Editors do not have to violate WP:3RR to edit war. If you know that, then good. When there is no consensus for your content and you just keep re-adding it against objection, that is edit warring. Three editors thus far have expressed concern regarding the content you added. And I still maintain that most of it should be moved to the "Society and culture" section and trimmed.

Since this page is on my watchlist, I prefer that editors don't ping me to it. If you'd rather not be pinged to it, I won't ping you either. Flyer22 Frozen (talk) 19:57, 6 December 2020 (UTC)

You seem not to have taken on board my submission when Kaldari's changes to a text that had stood for 6 years were made within two days of the talk page notification. Your addition as the third editor to support the changes occurred after my objections to Kaldari's modifications, and can certainly not be a factor in your construction of "an edit war". The second editor says "I certainly agree with some of this, and so is with difficulty shoehorned into your claim. How many edits in six years approved the impugned text? Imagine me to represent them. It's sort of lopsidedly for retention now, don't you agree? Magnovvig (talk) 11:56, 7 December 2020 (UTC)

Any thoughts from the other discussion page regulars? Crossroads? Mathglot? Kaldari (talk) 15:59, 8 December 2020 (UTC)

It's been 2 weeks now and the consensus seems to be to remove the T&P content except for the Bell v Tavistock case. Kaldari (talk) 02:54, 14 December 2020 (UTC)

I've refactored the material in question and added a sentence about puberty blocking legislation in the Unites States to provide some geographic balance. Kaldari (talk) 01:56, 15 December 2020 (UTC)

Problems with epidemiology

I cleaned up the epidemiology section of this article about a month ago. It was a confusing list of contradictory numbers, so I went through the cited sources to add context and structure. I realized as I was reading the papers that although they claimed to be assessing the rates of gender dysphoria, most of them were not doing any assessment of distress levels, and so were not finding rates of gender dysphoria, but instead rates of gender variance, transgender identity, or other gender nonconformity.

The cited studies do not assess the epidemiology of gender dysphoria. In fact, I could not find any studies that assess the rates of gender dysphoria, as defined within this article. However, I also don't know of any reliable sources that point out this lack of research. Therefore, by my understanding of WP:OR, I cannot raise this problem with the research within the text of the article. So, my question is: What should be done about the epidemiology section? Should it be left as is? Removed? Edited somehow?

Thanks, Of the universe (talk) 00:20, 17 January 2021 (UTC)

Come to think of it. You do make a point, sure a lot of individuals who are transgender have Gender Dysphoria.

But, you don’t need Gender Dysphoria to be trans. Not to mention there are individuals who have Gender Dysphoria and aren’t trans. CycoMa (talk) 01:25, 17 January 2021 (UTC)

Of the universe, you said, although [the papers] claimed to be assessing the rates of gender dysphoria... That's all we go by, per WP:Original research. You seem to then argue that those papers have it wrong and were not properly measuring gender dysphoria, so they should be discounted. However, we have to leave that to the experts, even if editors may feel the experts got it wrong. In other words, we can't use our own original research to say that those sources are not actually about the topic. Crossroads ^-talk- 05:14, 17 January 2021 (UTC)

I'm not advocating for anything specific here, more just making a note of the discrepancy on the talk page. And I should speak more precisely, I don't think the experts are wrong, per se: A lot of these are review papers that broadly cover both the epidemiology of gender dysphoria and the prevalence of transgender identity. Consider, for example, Zucker 2017 https://www.publish.csiro.au/sh/SH17067. Based on the title, "Epidemiology of gender dysphoria and transgender identity," one might assume that the prevalence numbers within the paper will include an estimate of the prevalence of gender dysphoria. However, no such estimate is made. Instead, Zucker synthesizes the prevalence/incedence/etc rates that various studies found for various markers of gender variance. Zucker makes no comment on whether these estimates are for "gender dysphoria" or for "transgender identity" (he presumably recognizes that these are two different things, but he seems indifferent to the classification... he's using "gender dysphoria and transgender identity" as a catch-all term).

So then the question arises, what is the appropriate way to summarize these types of results in an encyclopedia without editorializing? The article cites Zucker and says "1 in 12,000 natal male adults and 1 in 30,000 natal female adults seek out sex reassignment surgery," which seems to me to imply by juxtaposition that Zucker endorses this number as an estimate of gender dysphoria, when in reality Zucker makes no mention of whether or not the rate of sex reassignment surgery is a good estimate for gender dysphoria.

So, one possible answer could be "delete it if the author does not specifically say that an estimate is "gender dysphoria," but that would mean deleting almost the entire section, and seems like overkill to me, especially given that these papers tend to have "gender dysphoria" in the title. But, still, I'm not sure what the appropriate way to frame the information is. Maybe it's fine the way it is. Of the universe (talk) 09:47, 17 January 2021 (UTC)

DSM-5 is not the last word on all mental health topics

I added contrasting data from ICD-11 (diff), with the edit note, "DSM-5 is not the last word on all mental health topics. **Please discuss on TALK page before reflexively reverting this edit.**"

The statement, "The ICD-11, which will come into effect on 1 January 2022", which occurs in the diagnosis section of the article, might imply to some that ICD-11 is somehow inconsequential, which of course is not true. See my references to the ICD-11 Implementation or Transition Guide. Also note that Google Scholar already lists 28000 publications that include the exact phrase, "ICD-11" in the article or book chapter, and 986 publications with that exact phrase in the article title. Even considering the fact that Google Scholar includes grey literature, that is still a lot of research on a nosological manual that some (seem to) regard as unimportant. [Note: I need to go for a bit, so this Talk page entry is incomplete.] Mark D Worthen PsyD (talk) [he/his/him] 19:51, 26 January 2021 (UTC)

On mental health topics, the DSM-5 carries far more WP:WEIGHT than the ICD-11. The DSM-5 is the psychiatric bible. And this applies worldwide. We have been over this before. This article is not about mere gender incongruence or gender nonconformity. Crossroads ^-talk- 07:13, 27 January 2021 (UTC)

You are mistaken, and the previous discussion you referenced is not persuasive. Mark D Worthen PsyD (talk) [he/his/him] 17:45, 27 January 2021 (UTC)

P.S. You might have meant these two sections of the talk page, as they discuss ICD-11 in much more detail: Let's move away from U.S.-centric articles (DSM-5 vs. ICD-11) and Recent lead changes. Mark D Worthen PsyD (talk) [he/his/him] 17:54, 27 January 2021 (UTC)

All those previous discussions, from around the same time, show that most editors did not agree with what you were/are proposing. And the evidence for my statements is located there. Crossroads ^-talk- 20:10, 27 January 2021 (UTC)

I don't agree with your summary of those discussions, but I was trying to help you out (which means making my argument more difficult) with a more accurate reference. Mark D Worthen PsyD (talk) [he/his/him] 16:35, 28 January 2021 (UTC)

If ICD-11 doesn't come into effect until next year, I'm skeptical we should be citing it at all, since it may be substantively revised before then. As a process and a working draft it has a lot of buy-in, but it's not a completed work yet. Anyway, if there's MEDRS consensus that we're going to treat ICD-11 as a completely reliable source, then at best we have a conflict between reliable sources and have to lay out what those conflicts are, not try to pick which "side" of the conflict we like better. This would not be the first time (e.g. DSV-5 dropped Asperger's, but various European researchers aren't entirely on board with just folding everything into "the spectrum"). However, it's also generally going to prove to be a correct statement that DSM-V has more weight on psych matters than does a manual for diagnosing "diseases" in general (gender dysphoria doesn't qualify as one). So WP:DUE is going to lean heavily in DSM's favor here.  — SMcCandlish ☏ ¢ 😼  23:48, 28 January 2021 (UTC)

Just a comment, fwiw: I don't think any one of these documents should be treated as a final word. Each one reflects the various compromises among the committees' members and factions who produce each document. That is, DSM-5 and ICD-11 are much more like the position papers of the associations they come from, rather than a consensus of the current science, which how they have often been used in the past. It is the increasing influence of political factors in purportedly scientific documents that has itself become a controversy in sex research.— James Cantor (talk) 01:14, 30 January 2021 (UTC)

@James Cantor: Both organizations do try to support their nosological systems with a consensus of the current science, and in many (but not all) instances I think they do a good job of that. At the same time, sociocultural influences certainly play a role, and I wholeheartily agree with your main point that neither system should be treated as the final word. Mark D Worthen PsyD (talk) [he/his/him] 17:27, 31 January 2021 (UTC)

"Assigned gender" vs "sex assigned at birth"

I changed the first sentence of the article to read "a mismatch between their gender identity and their assigned gender (often their sex assigned at birth)" to better reflect the DSM definition. Another user changed it back to "mismatch between their gender identity and their sex assigned at birth," saying "These are the same thing. Neither the DSM or any other source suggests otherwise. We will use the most common term per WP:Due weight and WP:OR"

Assigned gender and sex assigned at birth are not the same thing. I understand that saying they are different could be classified as Original Research, although in my opinion, I am merely summarizing what the DSM says and avoiding mischaracterizing it. The burden of proof should be on saying that "assigned gender" and "sex assigned at birth" are synonymous. When in doubt, maintain the original wording from the source.

To explain the difference:

Sex assignment can be more complicated than at-birth sex assignment for intersex individuals who, for example, may be assigned female at birth and then go through male puberty. Furthermore, assigned gender does not always match assigned sex: Afab/amab nonbinary people and detransitioners can acquire male/female sex characteristics (eg facial hair or breasts) from HRT that cause them to be perceived as men/women and cause clinically significant distress. The DSM is clearly deliberately worded to be broad enough in scope to cover the complicated experiences that intersex people, nonbinary people, and detransitioners can have with gender, avoiding framing the diagnosis in terms of natal sex assignment.

For example "A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender."

The DSM also makes it explicitly clear that the diagnosis is meant to apply to intersex people: "Specify if: With a disorder of sex development (eg a congentital adrenogential disorder..."

Of the universe (talk) 23:39, 16 January 2021 (UTC)

The review paper (Zucker, et al. 2016) cited in the "Signs and symptoms" section of the article draws a distinction between assigned sex/gender and sex assigned at birth:

"The term “gender dysphoria” was first introduced by Fisk (1974) to describe individuals who experience sufficient discomfort with their biological sex to form the wish for sex reassignment. In the DSM-5, GD is defined as "an individual's affective/cognitive discontent with the assigned gender [usually at birth and referred to as natal gender]"" (emphasis added)

"Usually," i.e. not always.

Of the universe (talk) 23:49, 16 January 2021 (UTC)

References

I mean, if you really feel it's an improvement, why not remove "at birth"? The rest is a lot of OR, and I don't think much of your analysis is accurate anyway (people viewing a stranger's gender based on physical attributes changes their "assigned gender"? Huh?) Equivamp - talk 13:48, 17 January 2021 (UTC)

"Assigned [male/female] at birth" and "sex assigned at birth" are terminology used for medical assignment (often with surgical adjustment) in cases of intersex babies. The misappropriation of this phrasing in activistic sectors for use with regard to transgender persons not born physically intersex is intentionally confusing (attempting to blur further any lines between sex and gender) and is basically WP:FRINGE stuff. It is not how many high-quality medical sources approach these topics, and we should not engage in it here. It's unfortunate that some writers, either without a good sense of clarity, or also intentionally blurring lines for socio-politicized reasons, are using half-and-half expressions like "assigned gender" or "gender assigned at birth", but this is basically meaningless drivel. It's not possible to "assign" or otherwise impose a socio-mental construct on someone at birth when they do not have sufficiently developed brains to engage in any form of abstraction. Babies who are not intersex are observed (not "assigned") to have a particular biological sex at birth. Gender is a later combination (sometimes a dissonant oil-and-water combination) of innate and social factors, primarily psychological, that affect a person as they grow from babyhood. We need to avoid confusing these things. If they were not distinct in reality, then gender dysphoria (and trans, for that matter) would not be possible in the first place. There cannot be a mismatch between one's perceived gender and one's observed biological/genetic sex (plus the socially-imposed typical gender expectations that pertain to that sex – which are culturally variable) if these things are synonymous or if one is not real.  — SMcCandlish ☏ ¢ 😼  00:10, 29 January 2021 (UTC)

What language do you think would be most appropriate, then? Of the universe (talk) 22:40, 9 February 2021 (UTC)

Causes section - more text and references needed

I made a couple of edits to the causes section (diff), but the section would benefit from expansion (another paragraph or so) and we need more references regarding societal (and cultural, familial, medical, etc.) causes of dysphoria and distress, e.g., stigmatization, discrimination, etc. Mark D Worthen PsyD (talk) [he/his/him] 21:11, 26 January 2021 (UTC)

It is not a mere "diagnosis" that is partially caused by genes, but the underlying condition itself. As for the claim "the prevailing view is that societal discrimination and stigmatization are the primary causes of distress or dysphoria among gender nonconforming individuals", where is that supported in this? Please provide a quote. Crossroads ^-talk- 07:20, 27 January 2021 (UTC)

Yeah, that sounds like OR and confusion. A diagnosis is "caused" by a medical professional doing an evaluation and coming to a decision. A diagnosis is a subjective external viewpoint about – an abstraction regarding – a condition; it is not the condition. This is a general semantics error, like confusing a recipe with food, mistaking a map for actual land. Markworthen may be correct that we need expanded material in this section, but it should not look anything like that.  — SMcCandlish ☏ ¢ 😼  23:39, 28 January 2021 (UTC)

What is "the condition" then? Mark D Worthen PsyD (talk) [he/his/him] 04:14, 13 February 2021 (UTC)

In response to Crossroads - I should not have written "the primary causes" because that has not yet been clearly established. ¶ See page 4 of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People for this quote:

Unfortunately, there is stigma attached to gender nonconformity in many societies around the world. Such stigma can lead to prejudice and discrimination, resulting in “minority stress” (I. H. Meyer, 2003). Minority stress is unique (additive to general stressors experienced by all people), socially based, and chronic, and may make transsexual, transgender, and gender nonconforming individuals more vulnerable to developing mental health concerns such as anxiety and depression (Institute of Medicine, 2011). In addition to prejudice and discrimination in society at large, stigma can contribute to abuse and neglect in one’s relationships with peers and family members, which in turn can lead to psychological distress. However, these symptoms are socially induced and are not inherent to being transsexual, transgender, or gender nonconforming.

Mark D Worthen PsyD (talk) [he/his/him] 05:11, 13 February 2021 (UTC)

Removing statement with a primary source as reference

"Studies indicate that transgender people have an extremely high rate of suicide attempts; one study of 6,450 transgender people in the United States found 41% had attempted suicide, compared to a national average of 1.6%. It was also found that suicide attempts were less common among transgender people who said their family ties had remained strong after they came out, but even transgender people at comparatively low risk were still much more likely to have attempted suicide than the general population."

I want to remove the above section as it is WP:PRIMARY. I wondered if this was OK?

Onebrickatatime (talk) 08:48, 28 February 2021 (UTC)

Low and very low quality of evidence for hormonal and surgical treatment

Hi, I would be grateful for advice as how to reference https://academic.oup.com/jcem/article/102/11/3869/4157558 . It starts with a list of recommendations and then "GRADE" symbols next to them, such as

(1 |⊕⊕○○)

The symbols mean "very low" ⊕, "low" ⊕⊕, "moderate" ⊕⊕⊕ and "high" ⊕⊕⊕⊕ quality of evidence. (https://academic.oup.com/jcem/article/102/11/3869/4157558#99603252 )

In the recommendations for treatment, the only ones which are not low or very low quality are:

1.5 (advise to preserve fertility), 3.1 (confirm diagnostic criteria and criteria for endocrine phase), 3.2 (address medical conditions that can be exacerbated)

The rest of the recommendations for hormonal and surgical treatment in this clinical guideline have either no "GRADE" (e.g. 5.2, 5.3) or are tied to low quality or very low quality evidence. Should this information just be put into the reference somehow, with the statement that most of the evidence is of low or very low quality? Thank you very much! Jdbrook (talk) 19:31, 25 February 2021 (UTC)

Sorry, just corrected header, this paper deals with surgical and hormonal treatment, not just hormones, corrected the header of this discussion. Thanks! Jdbrook (talk) 19:32, 25 February 2021 (UTC)

I noticed that system, but as noted some of the entries do have 3 or 4 circle-cross-thingies. Could you put down what you think should be added to the article followed by the quote of the source (including the circle things) that supports it? The statements should be reasonably specific and hold closely in meaning to the source. Crossroads ^-talk- 07:18, 27 February 2021 (UTC)

Hi, thank you. I was thinking of something like

Most of the evidence basis for hormonal and surgical treatment recommendations is of low or very low quality.[1]

and then in the reference itself put the discussion:

Using the GRADE system here, recommendation evidence quality here was "very low" ⊕ or "low" ⊕⊕, except for considering fertility preserving options (1.5), confirming the diagnostic criteria for GD and the endocrine phase (3.1) and taking into account "medical conditions that can be exacerbated" (3.2), which were "moderate" quality ⊕⊕⊕, and recommendations 1.1, 1.2, 1.3, 4.7, 5.2, 5.3 with no evidence GRADE.

Is that too verbose? It is also possible to just list the 3 recommendations with "moderate" quality by number (1.5,3.1,3.2). Going the other way, more verbose, for ungraded recommendations, I could also have instead of just "1.1, 1.2, 1.3, 4.7, 5.2, 5.3" some more information about them, i.e., 1.1,1.2,1.3 (mental health professionals), 4.7 (total hysterectomy), 5.2,5.3 (hormone requirements before surgery, coordination with surgeon). But that is even longer, and it already seems pretty long.

Maybe it is best to also drop the 2 links within the reference itself? Those went to specific sections, exactly the parts in the article describing the GRADE system and the recommendations. I was trying to put in a highlighted phrase, but it seems those are reserved for links to Wikipedia pages, and the way I have it now creates even more references. It seemed useful to have these specific pointers to the source because they did not number the main sections, but perhaps readers can find the specific information easily enough if they'd like. What do you advise?

There is also another statement about evidence for adolescents in particular that would also fit right after the proposed sentence above, in the main text (from the talk section regarding psychotherapy, above this one).

Hormonal treatment recommendations for adolescents have "no clear consensus" because of the lack of long term data. [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841333 ]

So a possible full text addition is:

Most of the evidence basis for hormonal and surgical treatment recommendations is of low or very low quality.[2] Hormonal treatment recommendations for adolescents have "no clear consensus" because of the lack of long term data. [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841333 ]

What do you recommend? Thanks! Jdbrook (talk) 14:20, 27 February 2021 (UTC)

So, going off the "possible full text addition" towards the end of your last post, that first sentence seems to arise from a misunderstanding of that source, which is admittedly not too clear. Those recommendations seem to take hormone treatment itself as a given and be about how it is done. The paper's abstract states, "They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender." This is in line with other sources. Also, your proposed sentence speaks of "recommendations", but that is too vague. Regarding the second sentence, "recommendations" should be removed as not in the source and of unclear meaning, but the point of the sentence seems to be supported and the source is a review article, so you're basically good there as far as I can tell. Crossroads ^-talk- 06:34, 28 February 2021 (UTC)

Hi, thank you. The sentence claims the recommendations about medical approaches are based on low and very low quality evidence. The section with evidence ratings is "summary of recommendations" section: https://academic.oup.com/jcem/article/102/11/3869/4157558#99603239 . So it could be just the doses, etc., and still be correct, I think, it would still be the quality of the recommendations, and useful information, I think? But it seems wider ranging than the abstract, as this section also recommends who can do diagnoses, and how to initiate care and when one can consider surgery. For instance, recommendation 2.1 says

We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.

with ⊕⊕○○, a low quality evidence recommendation. So is:

In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.

also ⊕⊕○○, low quality evidence. These both seem to be recommendations about when and how to initiate treatment, and their low quality seems consistent with the second suggested sentence, which also notes a dearth of evidence. The first suggested statement is saying that the evidence basis for the puberty blocker, hormonal and surgical recommendations, i.e., this section, is almost all of low or very low quality, initiation and the rest, which is correct, isn't it? As long as the caveats about the +++ ones and the ungraded ones are included to make it precise, as you suggested, and I now realize it also includes puberty blockers, which I forgot. (These drugs are all off-label, so the evidence quality is likely useful to know-maybe their being off-label should be noted also?) Would it perhaps be better to, for instance, reference the "recommendations" section directly, so it is a clear and exact statement where one can see exactly what is meant, rather than the insufficient abstract? Perhaps that would clarify? Does that work?

Most of the evidence basis for puberty blocker, hormonal and surgical treatment recommendations is of low or very low quality.[3]

For the other sentence, I tried to clean it up, but ended up quoting most of it, I think that isn't ideal?

For adolescents, there is "no clear consensus regarding hormonal treatment," "because long-term data are unavailable." [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841333]

Thank you for the help! Jdbrook (talk) 07:49, 28 February 2021 (UTC)

I'm not sure I'm understanding all this correctly. Regarding that first proposed sentence, you would need to state what the recommendations are first, for balance and WP:NPOV. Also, you only quoted material about adolescents, so the sentence should stick to that. Lastly, the quote of the source starting with In adolescents who request sex hormone treatment... is unclear if it is talking about hormone therapy in general or just a particular way of doing it. The source is annoyingly unclear, but we need to really be careful to stick closely to the meaning therein and also to avoid (possibly accidental) cherry-picking. Crossroads ^-talk- 05:52, 1 March 2021 (UTC)

References

Hi thank you. The article is mostly a list of recommendations and their evidence.

6 are ungraded:1.1, 1.2, 1.3 (defining mental health professionals), 4.7 (clinicians decide medical necessity of total hysterectomy), 5.2 (timing of surgery wrt hormones), 5.3 (role of clinician approving surgery)

5 are "very low": 2.3, 3.4, 4.6, 5.4, 5.6

14 are "low": 1.4, 2.1, 2.2, 2.3, 2.4, 2.6, 3.3, 4.1, 4.2, 4.3, 4.4, 4.5, 5.1, 5.5

3 are "moderate":1.5, 3.1, 3.2

So 6 have ungraded evidence, 19 are low or very low quality,and 3 have moderate quality of evidence. How about:

"Most of the evidence for puberty blocker, hormonal and surgical treatment is of low quality, very low quality, or ungraded quality."

and then in the reference say:

"https://doi.org/10.1210/jc.2017-01658, Using the GRADE system, recommendation evidence quality was “very low quality” ⊕, for 5, “low quality” ⊕⊕, for 14, and “moderate quality" ⊕⊕⊕ for 3 (inform person to consider fertility preserving options, 1.5, confirming the diagnostic criteria for GD and the endocrine phase, 3.1,taking into account “medical conditions that can be exacerbated”, 3.2). No evidence GRADE was given for 6 (appropriate mental health professionals, 1.1,1.2,1.3, clinicians determine medical necessity of total hysterectomy, 4.7, hormone requirements before surgery, 5.2, role of clinician, coordination with surgeon, 5.3). "

To make sure this isn't cherry picking, here are more details about the evidence, from the paper:

In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); (2) the effects of treatment in adults on sex hormone levels; (3) the requirement for and the effects of progestins and other agents used to suppress endogenous sex steroids during treatment; and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people.

They say risks and benefits for older transgender people. For adolescents they say "Recommendations 2.1 to 2.3 are supported by a prospective follow-up study from The Netherlands. " This is cherry picking on their part, actually. The Netherlands study had very restrictive criteria for medical treatment, which the authors here do not mention. (There is only one Netherlands study and it is considered the gold sample, so the reference is unambiguous.) The positive outcomes in that study applied to treatments of 55 young people who satisfied the following:

(1) the presence of gender dysphoria from early childhood on; (2) an exacerbation of the gender dysphoria after the first signs of puberty; (3) the absence of psychiatric comorbidity that would interfere with a diagnostic evaluation or treatment; (4) adequate psychological and social support during treatment; and (5) a demonstration of knowledge of the sex/gender reassignment process.” Zucker 2019

The lead author of that work has just published an article saying it is a question whether their study outcomes apply more generally, to older adolescents with later than early childhood onset, for instance.

Here are other discussions about the evidence in the paper.

A systematic review of the literature found that data were insufficient (due to very low–quality evidence) to allow a meaningful assessment of patient-important outcomes, such as death, stroke, myocardial infarction, or VTE in transgender males (176). Future research is needed to ascertain the potential harm of hormonal therapies (176).

Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult.

Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).

What do you think?

Thanks! Jdbrook (talk) 14:55, 1 March 2021 (UTC)

Your proposed text heavily implies that there is weak evidence supporting hormonal or surgical treatment at all, but the source's recommendations appear to take those as a given and be about the details of the treatment. Your other quotes from the source are mainly about what is needed in future research, and material based on those quotes could perhaps be mentioned as it shows where knowledge gaps are; but that doesn't support "Most of the evidence for puberty blocker, hormonal and surgical treatment is of low quality, very low quality, or ungraded quality." And specifying types of "quality" like that outside the technical source would read oddly. Unless this source specifically states that hormones and surgery, in and of itself, has low quality evidence behind it, it's best to move on to other material from the source or another source. Crossroads ^-talk- 06:38, 2 March 2021 (UTC)

Oh, I think I see what you are saying....if someone said “he successfully took medicine for his headache,” this could either be that he succeeded in taking the medicine (the procedure) or that the procedure was successful (the headache is gone). Here it would be that the hormones changed the person's hormonal levels and that the puberty blockers blocked puberty and that the surgery changed the person’s shape, for the former, and for the latter, that these helped the gender dysphoria. It seems that the article addresses both (e.g. 2.1, 2.2 talks about mental health outcomes, but 2.3-2.6 are about medical procedures), but seems to be more focused on the procedures. (The surgery section again talks about both, e.g. “We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.”)

It is a high quality reference, literally the top of the pyramid (left hand figure) in WP:MEDRS as it is a set of clinical practice guidelines from the Endocrine Society, and is cosponsored (the asterisk) by American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Pediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and World Professional Association for Transgender Health. WP:MEDRS mentions guidelines can have “assessments of underlying evidence”, and this paper in fact uses a standard and respected process for evaluating clinical evidence, the GRADE system. The 156 papers which have referenced it since (according to PubMed) do not seem to be noting that they disagree with the GRADES, some do worry about the low quality evidence and there should be more research to improve evidence quality (which these authors also say). To take the most conservative view and say that it at least is talking about the procedures, one could say:

Most of the evidence for puberty blocker, hormonal and surgical treatment procedures has been assessed to be low quality, very low quality, or ungraded quality. [ref] 

and then in the reference say:

https://doi.org/10.1210/jc.2017-01658, Using the GRADE system, evidence quality for recommended procedures was “very low quality” ⊕, for 5, “low quality” ⊕⊕, for 14, and “moderate quality" ⊕⊕⊕ for 3 (inform person to consider fertility preserving options, 1.5, confirming the diagnostic criteria for GD and the endocrine phase, 3.1, taking into account “medical conditions that can be exacerbated”, 3.2). No evidence GRADE was given for 6 (appropriate mental health professionals, 1.1, 1.2, 1.3, clinicians determine medical necessity of total hysterectomy, 4.7, hormone requirements before surgery, 5.2, role of clinician, coordination with surgeon, 5.3). 

Does that work? It is one of the highest quality references out there because of the "GRADEs", the guideline status, the date (recent) and the organization(s) involved.

Maybe that would help clarify? Thanks! Jdbrook (talk) 04:16, 3 March 2021 (UTC)

This proposal still makes it seem like there is low evidence for hormones and surgery in and of itself, but I'm not getting that from the source. It seems to be talking about the specific details and rating that, and taking the hormone and surgery treatment itself as a given, as I've said. Yes, it is a very high quality source, but if it doesn't support something, then that's that. Crossroads ^-talk- 05:35, 3 March 2021 (UTC)

I am definitely not interested in saying something which is not supported by the reference. Thank you for explaining how it reads to you. I think I am understanding your concern, and absolutely do not want to depart from the supported evidence in this high quality source. How about:

Current recommended procedures for puberty blockers, hormones and surgery are based upon evidence which is mostly low, very low, or ungraded quality.[ref]

And then the reference as above?

"https://doi.org/10.1210/jc.2017-01658, Using the GRADE system, recommendation evidence quality was “very low quality” ⊕, for 5, “low quality” ⊕⊕, for 14, and “moderate quality" ⊕⊕⊕ for 3 (inform person to consider fertility preserving options, 1.5, confirming the diagnostic criteria for GD and the endocrine phase, 3.1,taking into account “medical conditions that can be exacerbated”, 3.2). No evidence GRADE was given for 6 (appropriate mental health professionals, 1.1,1.2,1.3, clinicians determine medical necessity of total hysterectomy, 4.7, hormone requirements before surgery, 5.2, role of clinician, coordination with surgeon, 5.3). "

I think that wording, emphasizing "procedures", avoids implying the problematic things you are pointing out? The quality of the evidence for treatment procedures seems highly relevant to me, for a section informing people about treatments. I hope this has corrected the unintentional ambiguity that you saw in my earlier phrasing!

Thanks! Jdbrook (talk) 19:59, 3 March 2021 (UTC)

This has the same problem of implying something about the whole set of treatments itself. There would only be a case to include if the article went over these minutiae of treatment, but it doesn't and won't because of WP:NOT; Wikipedia is not any of a number of overly detailed things, including a medical manual. I don't see anything left to discuss on that sentence. Maybe another editor who watches this page wishes to chime in on it. Crossroads ^-talk- 06:23, 4 March 2021 (UTC)

Here is what the earlier version of the guidelines (2009) said:

The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.

It is also true for the later article, which supersedes it and includes surgery. Practice guidelines for puberty blocker, hormonal and surgical (in the later article) treatment are based upon evidence which is mostly low, very low or ungraded. (Or, if you prefer, endocrine and surgical treatment.) Why is this high quality information not relevant for the section on biological treatment?

Thanks! Jdbrook (talk) 14:16, 4 March 2021 (UTC)

I can't speak for anyone else, but to me it looks like these statements are being cited out context and in a way that doesn't follow the authors' intentions, in a way that amounts to WP:OR. Newimpartial (talk) 15:07, 4 March 2021 (UTC)

Hi, thank you, can you please clarify? I've given the abstract of the earlier (2009) guidelines, green box above, which is close to the wording I suggested, but I then updated it, since the new guidelines (2017) include surgery, and also ungraded evidence. Why is the abstract of the earlier version, updated, an out of context citation? What wording would you suggest, closer to the guidelines, to indicate the evidence quality for the recommended procedures? I am very interested in accurately representing what they say. Thanks for the help, everyone! Jdbrook (talk) 20:57, 4 March 2021 (UTC)

What part of either article supports Current recommended procedures for puberty blockers, hormones and surgery are based upon? That is the part that reads to me as WP:OR. Newimpartial (talk) 21:40, 4 March 2021 (UTC)

Hi, thank you. The title of the paper is "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline" and it then is a list of recommendations and their evidence basis. As you saw above, and as they noted in the 2009 version, most of the recommendations have a low quality or very low quality (or, in the 2017 one, ungraded quality) evidence basis. In the 2009 paper, they say in the abstract (copied from above):

The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.

This doesn't seem to me to be WP:OR, the GRADES are in the summary of the paper, at the beginning here. I did count them to verify it was accurate to say that most of them were "low quality", "very low quality" or "ungraded quality". It is appropriate for the guidelines, as the 2009 version listed that statement in its abstract. The section headers in the summary of recommendations and GRADES are roughly evaluation (mostly ungraded), adolescents (including puberty blockers), hormonal therapy, adverse outcome prevention, and surgery. That is where I got the statement that this was for puberty blockers, hormones and surgery. What would you suggest? Would "the practice guideline recommendations for puberty blockers, hormones and surgery are based mostly upon low quality, very low quality and ungraded evidence" be closer to what the paper says? I added procedure since that seemed clearer, but now it sounds like it is not appropriate. Thanks! Jdbrook (talk) 22:04, 4 March 2021 (UTC)

My evaluation is that any such isolation of a list of procedures noting that they are based mostly upon low quality, very low quality and ungraded evidence constitutes WP:OR in this context, since this evidence and conclusion do not appear in either study. Newimpartial (talk) 23:31, 4 March 2021 (UTC)

Thank you. Can you please clarify? The evidence is listed in the study, in the main body, to support the guidelines, the headers say "Evidence" for each. The GRADEs are in the summary, with evidence quality listed for each recommendation: "very low" ⊕, "low" ⊕⊕, "moderate" ⊕⊕⊕ , "high" ⊕⊕⊕⊕ and "ungraded" quality of evidence, and in the body with each corresponding recommendation. The suggested reference would have the counts, of each, to be specific for the reader, but paraphrasing seemed more appropriate for the main text. The conclusion about the quality of evidence being "low" or "very low" is in the first two sentences of the abstract of the 2009 paper, quoted in the green box right above your statement. Low evidence and very low evidence quality is also found for most of the 2017 paper recommendations, although they also had ungraded quality there, and 3 which were moderate. So you prefer: "Most of the guidelines for endocrine treatment of gender-dysphoric/gender-incongruent persons are based upon "low" quality, "very low" quality and ungraded quality evidence"? And then the reader can look to see that "endocrine treatment" means puberty blockers, hormones and surgery? Is that more accurate? The 2009 paper abstract can be used, it is just that the 2017 is more recent. What do you think? Thanks! Jdbrook (talk) 23:56, 4 March 2021 (UTC)

Agreeing with newimpartial that this is likely OR and agreeing with Crossroads about jdbrooks proposals not being represented by what the author is saying. Rab V (talk) 12:45, 6 March 2021 (UTC)

Hi, thank you for explaining. It seems that by Wikipedia policies, two correct statements from the current 2017 high quality guidelines, which also lists approval from WPATH in the header would be:

More rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols are needed.

This is a rearrangement of the wording of a single sentence in the text.

"Future research is needed to ascertain the potential harm of hormonal therapies."

Is exact. Please advise?

It seems these statements are in accordance with the standards we are trying to follow?

How do you suggest incorporating this information from high quality sources on the page? It seems important and relevant.

Thanks! Jdbrook (talk) 15:28, 6 March 2021 (UTC)

There is a clear difference between a source stating, "more rigorous evaluations/future research is needed", and a statement that "most of the guidelines for treatment are based on low/very low/ungraded quality evidence", which is what you had previously proposed. Newimpartial (talk) 15:43, 6 March 2021 (UTC)

Yes, we agree they are different!

Is it ok to put in these two statements as we agree (I think, I hope!) they are clearly in the guidelines?

More rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols are needed.

and some paraphrase of (as it is exact wording right now):

"Future research is needed to ascertain the potential harm of hormonal therapies."

As you noted, and I agree, these statements do not include the results of the Endocrine Society evidence grading, one of the results of the paper. The abstract of the paper says:

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence.

That is, the evidence based guidelines used a specific method to assess their evidence, which they report. This report of their results, the "GRADE"s, are what my earlier statement summarized. I don't see why reporting the grades they found, sorted by GRADE, is original research. The original research is what they are reporting, including creating these GRADES for the evidence. The suggested text was to summarize the fact that 3 were "moderate quality", the rest (25) were all "low quality", "very low quality" or ungraded, i.e., shortening that to "most recommendations were based upon evidence which was found to be low quality, very low quality or ungraded quality".

WP:OR says that original research is

research that is not exclusively based on a summary, review, or synthesis of earlier publications on the subject of research.

I don't see how counting the number of recommendations with each reported quality of evidence GRADE is not a summary of what the authors found for the evidence quality. Do you have a better way to summarize the preponderance of low, very low and ungraded quality evidence they found (with their original research) for their recommendations? Thank you for slogging through all of this, it seems complicated! Jdbrook (talk) 00:30, 7 March 2021 (UTC)

Re: I don't see how counting the number of recommendations with each reported quality of evidence GRADE is not a summary of what the authors found for the evidence quality. Do you have a better way to summarize the preponderance of low, very low and ungraded quality evidence they found (with their original research) for their recommendations? I don't see any way to summarize in the way you are suggesting without engaging in OR; if the authors of the study thought there to be an appropriate summary (besides "more research is required"), they would presumably have offered this summary themselves. Newimpartial (talk) 01:26, 7 March 2021 (UTC)

Wikipedia specifically says that summarizing is not OR (if the summary was listed in the text, then my saying it would not be summarizing, it would be simply quoting the text). But I see you find my summary too far from the article, which is not good. Perhaps the following is a better suggestion, and sidesteps the whole counting summary: do you think that it would be accurate to say that "the guideline recommendations for when and how to start young people on puberty blockers, and who should do so, and when and how to start adolescents on hormones are based on low quality GRADE evidence"? (Those are 2.2, 2.3, 2.1,2.4. respectively in [4]) This is much closer to the text, less vague, I like it better, actually, maybe you do, too? Maybe this is much cleaner? Thanks for all your help with this! Jdbrook (talk) 05:11, 7 March 2021 (UTC)

Why is this sentence ok by Wikipedia guidelines?

Resolved

The sentence:

The overall level of patient satisfaction with both psychological and biological treatments is very high.[46]

refers to Gijs, L; Brawaeys, A (2007). "Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges". Annual Review of Sex Research. 18 (178–224). [5] Can someone please indicate how the article cited supports this sentence? Thank you! Jdbrook (talk) 05:07, 11 March 2021 (UTC)

Have you been able to access a copy to read it in full? If not, you can try WP:Resource exchange. If you have and that claim failed verification, then it should be changed to better summarize the source. Crossroads ^-talk- 07:12, 13 March 2021 (UTC)

I read the paper and it only addresses satisfaction with sex reassignment surgery:

Summarizing the results from the 18 outcome studies of the last 2 decades, the conclusion that SR is the most appropriate treatment to alleviate the suffering of extremely gender dysphoric individuals still stands: 96% of the persons who underwent SRS were satisfied and regret was rare.

I haven't looked to see if there are other papers addressing satisfaction with hormonal or psychological treatment. Note, however, that there are two very different kinds of psychological treatment presented in the medical literature: "gender-affirming therapy" (which supports gender transition) and psychotherapeutic "curing" (which does not). We should be careful to distinguish which one we are talking about. Kaldari (talk) 16:35, 13 March 2021 (UTC)

I changed the wording of the section to more accurately reflect the cited source. I was unable to find sources specifically about patient satisfaction for psychotherapy or hormone therapy, as the vast majority of the medical literature seems singularly focused on sex reassignment surgery, which is unfortunate. Kaldari (talk) 18:00, 13 March 2021 (UTC)

Thank you for handling this. Crossroads ^-talk- 05:09, 14 March 2021 (UTC)

Hi, @Kaldari: and @Crossroads:, thank you both for looking into this. For the cited quotation:

A 2007 review article found that 96% of patients who underwent surgical reassignment were satisfied and regret was rare.[18]

there is context for their results which is not there and seems important. Right after this quoted result, the paper goes on to say (I've just added boldface):

"Methodologically, however, this conclusion should be carefully qualified", "used only a posttest to measure the effects of SRS," "In many studies, sound psychometric instruments were not used. Especially disturbing is that many researchers did not directly measure gender dysphoria as the main outcome variable but instead used derivative measures..."

The following paragraph also notes some big issues about drawing any conclusions, loss to follow-up.

In addition to the design problems of the studies, patient numbers are seriously skewed. A large number of patients who received surgery were lost at follow-up (see Table 1): For the FMs the attrition rate varies between 0% and 81%, with an average of 24% (based on Boldund & Kullgren, 1996; Eldh et al., 1997; Hepp et al., 2002; Lobato et al., 2006; Raufleish et al., 1998; Smith et al., 2005a, Tsoi et al., 1995). For the MFs, between 0% and 73% did not participate in the follow-up, with an average attrition rate of 39%

This concern was later repeated by the endocrinology guidelines, a decade later, with more research results in hand and after applying a rigorous evaluation method:

Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult.

Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261).

Another analysis demonstrated that, despite the young average age at death following surgery and the relatively larger number of individuals with somatic morbidity, the study does not allow for determination of causal relationships between, for example, specific types of hormonal or surgical treatment received and somatic morbidity and mortality (263).

and

We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment.

That is, the results currently in the article have important qualifying statements, and that more recent work has not resolved these problems; there is a call for more research as a result of current ignorance about surgical outcomes and there are concerns about poor ones. So the current quotation is incomplete as it stands. What do you think? Maybe

A 2007 review article found that 96% of patients who underwent surgical reassignment were satisfied and regret was rare, however there were some methodological issues and significant loss to follow-up.[18] There is a need for more studies examining long term quality of life, psychosocial and psychiatric outcomes, with appropriate controls, to determine the long-term benefits of surgical treatment.[6]

It might be also relevant to mention the poor outcomes, there is a 2011 classic long term cohort study which showed significant mortality relative to controls (in part due to suicide, Fig. 1), [ https://doi.org/10.1371/journal.pone.0016885 here]? Maybe adding "especially in light of some reported long term pathology?" Thanks! Jdbrook (talk) 23:56, 14 March 2021 (UTC)

The sentence is about patient satisfaction, not mortality or outcomes. Also we don't cite primary studies (or at least we try not to). As for the methodology issues, this is an encyclopedia, not a medical journal article. We need to briefly summarize the information, not get deep into the weeds of analyzing the studies. I'm inclined to just delete the sentence if it's problematic. Kaldari (talk) 01:42, 15 March 2021 (UTC)

I deleted the sentence in question and also added another review article citation to the preceding sentence. Hopefully that addresses the concerns. If the reader wants more specific information, they are free to read the review articles for themselves to get the details (complete with caveats). Kaldari (talk) 03:05, 15 March 2021 (UTC)

Cannot find source of sentence

Hi all, can someone please advise where

Patients with severe GD report high levels of satisfaction with sex reassignment surgery.[18][50]

appears in either of the references cited? Thank you. Jdbrook (talk) 02:49, 15 March 2021 (UTC)

Just search for the word "satisfaction". Kaldari (talk) 03:07, 15 March 2021 (UTC)

Am I looking at the right references? Gijs and Brewaeys, 2007, Carroll, 1999? There is the word satisfaction a lot, but it is a dependent variable, or part of some outcome in some study, or they are trying to find correlations. I didn't see anything about "severe GD" patients reporting this. Could you please point me to the page or pages in either/both that you are referring to? Thanks! Jdbrook (talk) 03:58, 15 March 2021 (UTC)

From a cursory glance at Carroll 99, there's this on pg. 134:

We now have a clearer understanding of the heterogeneity of cross-gender behavior and identity. We also see that individuals with transgender experiences do not necessarily exhibit higher levels of mental disorders than the nonclinical population. There is clear evidence that the gender reassignment process results in significant improvement and satisfaction for the large majority of individuals who choose it.

I can't find any mention of only patients with severe GD having these high levels of satisfaction, so I would suggest removing the severe qualifier from the sentence. Srey Sros^talk 04:16, 15 March 2021 (UTC)

@Jdbrook: Here you go:

Summarizing the results from the 18 outcome studies of the last 2 decades, the conclusion that SR is the most appropriate treatment to alleviate the suffering of extremely gender dysphoric individuals still stands: 96% of the persons who underwent SRS were satisfied and regret was rare.
— Gijs & Brewaeys 2007, page 215

While it is easy to critique past studies, it must also be understood that there is much about the work with gender-dysphoric individuals that makes rigorous empirical research difficult to conduct... Fortunately there is a great deal of consistency in the findings of these studies... The single most consistent finding in the research on the psychosocial outcome of gender reassignment is that it results in improvement or a satisfactory outcome in two-thirds (Abramowitz, 1986) to 90% of patients (Green & Fleming, 1990). This finding appears to be true for both male and female transsexuals, with a variety of surgical, hormonal, and psychological interventions, when measured at widely varying points in time. Despite the limitations of the research and the variability in the results, this is a striking conclusion.
— Carroll 1999, page 132

...and also the quote given by SreySros above. The "severe GD" part was from when only the first review was cited (which says "extremely gender dysphoric individuals"). Given the information in the Carroll citation, I suppose we could change it (or remove the Carroll citation). Kaldari (talk) 04:24, 15 March 2021 (UTC)

That makes sense, it seems like the broader statement that Patients with severe GD report high levels of satisfaction with sex reassignment surgery is supported and still encompasses the previous statement. Since the context of that sentence in our article is not referring to severe GD specifically, I'll change that sentence to remove the qualifier. If anyone disagrees with that change, feel free to revert and state why here. Srey Sros^talk 04:35, 15 March 2021 (UTC)

Thank you all for explaining. Jdbrook (talk) 04:58, 15 March 2021 (UTC)