Talk:Standards of Care for the Health of Transgender and Gender Diverse People

Removed unsourced material

I removed A dramatic elevation in surgical and post-surgical risks as well as an increased possibility of post-surgical dissatisfaction is often the exchange for lower costs and fewer pre-surgical requirements such as weight limits. because a) it's unsourced b) it's a damaging lie about trans people. It's an old canard on the level of the Protocols of Zion lie about Jews. c) it's language is inflammatory. If such a claim is to be made 'dramaticly' needs defined.

Systematic review by University of York

I added the following text

In April 2024, paediatrician Hilary Cass, author of the Cass Review, wrote in the British Medical Journal that although WPATH has been "highly influential in directing international practice", an appraisal by the University of York found its guidelines to "lack developmental rigour and transparency". Some clinicians questioned the rejection by Cass of what she calls "poor quality" research.

about the WPATH guidelines from reliable secondary sources about a peer-reviewed systematic review:

• Guardian article Gender medicine ‘built on shaky foundations’, Cass review finds | Transgender | The Guardian
• PinkNews article Doctors question Cass report's dismissal of trans research (thepinknews.com)
• the peer-reviewed systematic review Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1) | Archives of Disease in Childhood (bmj.com) (accepted 15 December 2023)

Dear @Raladic let's have a discussion. I don't understand your objection to the text you removed, given these reliable sources.

AndyGordon (talk) 07:10, 22 April 2024 (UTC)

The systematic review is a top tier MEDRS, analysing multiple international guidelines in this area. It is relevant and due. I would suggest citing that directly and rephrasing to limit the commentary to only what is covered by the review. Void if removed (talk) 08:24, 22 April 2024 (UTC)

The problem with the text as you added is that it is an Opinion piece (https://www.bmj.com/content/385/bmj.q814) that is primary to Cass, it was quoted basically as is by the sources you added, but that nonetheless doesn’t make it an opinion and not RS. This article here is medical, so it requires MEDRS and the actual article on the Cass Review itself has an extensive criticism section of being criticized by most medical institutions including WPATH (so it’s somewhat circular), so adding this opinion quote of hers into here would not be appropriate and we should stick to the actual medical text of the peer reviewed systemic review, with note that it specifically analyzed SOC7 as they wrote most of their review prior to SOC8, which is the newer standard and was only cursory mentioned in the actual systemic review.

The other part of why I asked you to discuss this here first is that we avoid a pure WP:CRITS section that only focuses on criticism, it doesn’t matter if it is titled “Criticism” or “Reception” if the only content is negative, as that is just a criticism section in hiding, instead per our guidance, if we add a reception section it needs to be balanced, so it needs to also include the (in this case overwhelming) positive appraisal of the WPATH SOC since they are the de-facto medical worldwide standard on transgender care. Raladic (talk) 14:39, 22 April 2024 (UTC)

Interesting and thank you for the explanation. Reading WP:MEDRS and WP:MEDDEF in particular I'm wondering about the distinction there between biomedical information and general information. I think that statements about the quality of the review would be biomedical, whereas the statement about its influence on other guidelines would be general information. Anyhow, I will rephrase the text above using only the systematic review, and drop the final sentence "Some clinicians..." because it is biomedical and not supported by MEDRS.

To your point that it is a de-facto standard, there is material in the systematic review to the effect that the WPATH guidelines together with those of the Endocrine Society have influenced all the others, despite being of poor quality. So we should include a careful summary of that. AndyGordon (talk) 21:00, 22 April 2024 (UTC)

Ok, but also as I mentioned, before we can add any of this criticism, you will also need to create a balanced positive reception part of the SOC. Since while the Cass review criticized it for the purpose of guidance for the British NHS, the rest of the medical community around the world doesn’t share that sentiment, which is why many parts of the rest of the world do follow the SOC guidelines in their local country specific rules, or just outright use the SOC guidelines, such as is the case in the US. Raladic (talk) 21:17, 22 April 2024 (UTC)

I've made an attempt to include material just from the systematic review. AndyGordon (talk) 11:43, 26 April 2024 (UTC)

Lynne-Joseph quote

Hi @Raladic, hope you're having a nice day.

I just saw you reverted my edit. To allay your concerns:

• this is a secondary source; Lynne-Joseph actually cites this statement with two references of her own
• it's not that vague: it specifies two groups of people who share concerns over a lacking evidence base and cites two sources which can be examined for further detail
• it's a peer-reviewed article in Social Science & Medicine summarising prior findings in multiple other such articles elsewhere, so it isn't giving undue weight to a fringe opinion; you can also see this in a direct quote from a WPATH and USPATH member: "A lot of people had so many concerns about the SOC8 guidelines, because they were based on the opinions, quite frankly, not on the evidence, but on the anecdotal opinions of researchers who are cisgender" and the director of Belgium’s Center for Evidence-Based Medicine, who has said he would “toss them [WPATH’s guidelines] in the bin.”

Please let me know if you still have any issues. Thanks! 13tez (talk) 14:32, 5 May 2024 (UTC)

No, it’s portraying it in a way that tries to make it appear that a vague whole group (it reads as if all TGNC people and clinicians have criticized… are opposed to the SOC) is criticizing it, which is WP:UNDUE as it doesn’t specify who those people are and doesn’t make clear that very many other TGNC and clinicians are very much in support of SOC8 as it’s the de-facto gold standard for gender-affirming care worldwide and supported by clinicians from around the world.

As this article is about a medical topic, we have a specific guideline that spells. Please check out the recent discussion just above on Standards of Care for the Health of Transgender and Gender Diverse People#Systematic review by University of York on this which is why similarly, this section included just the systemic review paper in a narrow way as we don’t encourage extensive criticism sections without them having balance of supportive evaluation, which exists is large quantities and would have to be brought in, or else this just becomes a WP:CRITS section in disguise.

Aside from all that, the paper from Lynne-Joseph is about SOC8 and not SOC7, so if we were to include it, alongside a balanced discussion of the extensive worldwide support that the WPATH standard receives, it would have to go in the version 8 section. Raladic (talk) 16:25, 5 May 2024 (UTC)

Hi, thanks for your reply.

it’s portraying it in a way that tries to make it appear that a vague whole group (it reads as if all TGNC people and clinicians have criticized… are opposed to the SOC) is criticizing it

Not really. The quote is "TGNC people and clinicians have criticized the SOC for relying too heavily on expert opinion and called for updates that incorporate stronger evidence". The quote tells us that some number of TGNC and clinicians have made these criticisms, which is true. It doesn't say any specific number have done so, certainly not all or even a majority. To resolve this issue, however, would you prefer to paraphrase the quote to make it explicit that it is "some" of these people rather than all of them?

doesn’t make clear that very many other TGNC and clinicians are very much in support of SOC8

This isn't supported in this quote from this source, so we can't extract this information from it. Everything we include has to be verifiable via reliable sources. It is true but should be referenced from elsewhere - and should be to provide balance and context. Explaining that some support and some oppose the guidelines (and why) will also help us maintain a neutral point of view. I'm sure you'll agree the concerns (as well as praise) of medical professionals and patients, verifiable through multiple reliable and MEDRS sources, have due weight.

de-facto gold standard for gender-affirming care worldwide and supported by clinicians from around the world

It does have popular support, but doesn't have amazing credibility. As I've pointed out, there are several sources such as the systematic reviews in the Cass Review, the journal article in question here, the quotes from a WPATH and USPATH member and the director of Belgium’s Center for Evidence-Based Medicine (found in five minutes of googling) that all say the current guidelines in the SOC aren't sufficiently based on evidence. There are even further groups (Sweden, Ireland, Norway, and Finland, Denmark, the Netherlands, and the European Academy of Paediatrics) who believe that the current practice they set out isn't evidence-based or are going to carry out reviews because they share these concerns. There really isn't a consensus that the SOC "are correct". The best analysis to date, from the systematic reviews commissioned for the Cass Review and a Swedish systematic review, all say there isn't enough evidence to support current practice of the sort SOC recommends. The global standard will be set by the relevant WHO GDG.

'we don’t encourage extensive criticism sections without them having balance of supportive evaluation, which exists is large quantities and would have to be brought in, or else this just becomes a WP:CRITS section in disguise'

It should be fine to summarise the fact that relevant people both support and oppose the SOC and why, in the manner I talked about above. We should acknowledge and summarise both to maintain due weight and a neutral point of view. Would you prefer to summarise multiple sources into a single further sentence saying something like "Some medical professionals, TGNC people, and WPATH members have criticised the SOC for not being sufficiently evidence-based."? We can add the two news articles and the journal article in question to verify this and means we aren't listing out every single person who's said this, but still giving them some coverage (which is due). By summarising in a single sentence, we'll avoid a criticism section/article.

the paper from Lynne-Joseph is about SOC8 and not SOC7, so if we were to include it, alongside a balanced discussion of the extensive worldwide support that the WPATH standard receives, it would have to go in the version 8 section.

"In June 2017, the World Professional Association for Transgender Health (WPATH) announced a plan to revise its “Standards of Care” (SOC), a set of prominent clinical practice guidelines used in transgender medicine, for the eighth time to create SOC-8...TGNC people and clinicians have criticized the SOC for relying too heavily on expert opinion and called for updates that incorporate stronger evidence...Cognizant of the criticisms leveled by clinicians and patients alike, WPATH leadership radically changed the process for guideline development with the SOC-8. The process aimed to address ongoing tensions concurrently by...aligning the guidelines with the principles of evidence-based medicine (EBM)."

Thanks again. 13tez (talk) 19:01, 5 May 2024 (UTC)

There really isn't a consensus that the SOC "are correct". - The health organizations from most countries of the world following WPATH SOC is exactly that, it is their current medical consensus and for most countries considered the currently global standard.

The Cass Review itself has received extensive criticism from the medical community around the world and thus we should not put undue weight on it as it is a review, but it was created to inform the standards of one country, the UK, which the European Union itself has called out has regressed dramatically in trans rights in recent years.

So yes, we can of course include specific criticism if it is due, but we can not ONLY include this criticism, without also providing the counterbalance that the WPATH SOC is widely viewed as appropriate as exhibited by the many more countries following its recommendation versus some who have created their own standards. Otherwise it may appear that there is only criticism and no support, which would violate Wikipedias WP:NPOV policies. So an example on how this content could be included in a balanced way could be that you can go find the sources that cite how many other countries do follow the WPATH SOC standards and thus endorse them, versus the countries you just listed that have created their own standards or criticized it.

One other thing to note, we try to limit MOS:QUOTEs and instead summarize when we can.

So the point I was trying to make, was similar to the discussion I already referenced from above, that we have to maintain a neutral point of view when we add criticism content to an article to ensue it doesn't give WP:UNDUE weight to a particular view. Raladic (talk) 19:23, 5 May 2024 (UTC)

Thanks for getting back to me again.

The health organizations from most countries of the world following WPATH SOC is exactly that, it is their current medical consensus and for most countries considered the currently global standard.

Which countries (or their health organisations) follow the WPATH SOC and have their caregivers relying upon them (or legally obliged to follow them) as their primary guidelines in transgender care? I'm not aware of any at present.

The Cass Review itself has received extensive criticism from the medical community around the world

From groups like WPATH based on conventional wisdom. Systematic reviews are one of the highest levels of evidence (medicine should be based on evidence, not conventional wisdom), and the NHS is far more credible and reputable than any of the groups (I am aware of) who have criticised the review. A lot of criticism is also based on objectively false claims (e.g. that it dismissed 98% of studies).

we can of course include specific criticism if it is due, but we can not ONLY include this criticism, without also providing the counterbalance that the WPATH SOC is widely viewed as appropriate as exhibited by the many more countries following its recommendation...

OK then, I think we agree: we should include summaries of support and opposition. Can you verify that more countries support or follow the WPATH SOC than the number which don't? I ask because it would be relevant for inclusion here, and you've mentioned that "many more countries" support it and "most countries considered the currently global standard". Thanks! 13tez (talk) 20:10, 5 May 2024 (UTC)

There is no singular list, so you'll have to go to each countries medical board to pull it up for citation, but the WPATH SOC are translated into 18 languages, suggesting their adoption in many parts of the world of those languages, including Arabic, Chinese, Croatian, English, Finnish, French, German, Hindi, Italian, Japanese, Korean, Norwegian, Persian, Portuguese, Russian, Serbian, Spanish, Vietnamese, and Polish.

Also while above, you cited the Netherlands as criticizing it, they do in fact follow the WPATH guidelines in their Dutch protocol 2018 - so as you can see, if you only included some criticism, it could appear that the country would be seen ass against it, when in fact, they are following it.

This is the point of why we have WP:NPOV policies and particular caution has to be exercised when you want to add criticism without also doing the research of support, or trying to argue that you don't have to do this research yourself and only selectively adding the criticism, which is outlined in the WP:Criticism#Neutrality and verifiability essay with particular note about WP:WEIGHT, as otherwise it can be seen as pushing a certain WP:POV focussing only on the negativity. Raladic (talk) 20:34, 5 May 2024 (UTC)

Thanks for getting back to me again.

There is no singular list, so you'll have to go to each countries medical board to pull it up for citation, but the WPATH SOC are translated into 18 languages, suggesting their adoption in many parts of the world of those languages

That's helpful and a good place to start, but we need to verify which countries do follow the SOC in the manner I described. Translation into the language of a country, of course, isn't sufficient to substantiate that.

Also while above, you cited the Netherlands as criticizing it, they do in fact follow the WPATH guidelines in their Dutch protocol 2018

I was very careful with what I said: "who believe that the current practice they set out isn't evidence-based or are going to carry out reviews because they share these concerns". Even though most of the groups I listed are no longer carrying out treatments in the manner set out in the SOC, some are reviewing whether treatments should continue in that manner in light of recent findings that there is insufficient evidence to support them. The article says: "Even the original Dutch clinic is facing pressure to limit patients receiving the care...the Dutch Parliament passed a resolution to conduct research comparing the current Dutch approach with that of other European countries." In other words, they're now reviewing their current practice (and, given multiple other reviews have found it to be insufficiently supported by evidence, are likely to change it as a result).

This is the point of why we have WP:NPOV policies..

Yeah, I agree. I think we both understand that it's important to summarise both the support and opposition to the SOC and not go into extraneous detail (on either front) that would take up too much text or push either narrative.

Thanks! 13tez (talk) 20:55, 5 May 2024 (UTC)

Just a quick note on In other words, they're now reviewing their current practice (and, given multiple other reviews have found it to be insufficiently supported by evidence, are likely to change it as a result). - One of the core policies of Wikipedia is that we do not employ WP:CRYSTALBALL - so we do not make speculation of what may happen in the future and should not add content to that effect to articles. Raladic (talk) 21:00, 5 May 2024 (UTC)

SOC8 & York Systematic Review

@Flounder fillet the quote from the paper is:

The WPATH and Endocrine Society international guidelines, which like other guidance lack developmental rigour and transparency have, until recently, dominated the development of other guidelines.

The quote is that the WPATH guidelines "lack developmental rigour and transparency". This section does not specifically restrict that criticism to the SOC7, and table 1 shows SOC 7 and 8 scored 26% and 35% respectively for developmental rigour, while the two endocrine society guidelines scored 44% and 42%.

A key finding of this paper is that both WPATH SOC 7 and 8 lacked developmental rigour. This is not a criticism unique to 7, and it isn't stated as such in the quote.

Per your edit comment, this is supported by the source - both in the specifics of this quote and in the whole of the paper - and I ask you to self-revert. Void if removed (talk) 18:23, 7 May 2024 (UTC)

I think it's worth mentioning that Hall et al. describe the WPATH guidelines as lacking "developmental rigour and transparency", and it's evident that the paper is referring to both versions. On another note, VIR, which part supports your proposed "did not recommend its use". The source plainly urges caution when using the guidelines, but I'm not seeing a straightforward statement of recommendation that they be avoided. Firefangledfeathers (talk / contribs) 18:29, 7 May 2024 (UTC)

I was referring to this part:

Online supplemental table 3 shows the overall scores and assessment of whether guidelines should be recommended for practice. Only two guidelines were recommended for practice by all three appraisers: the Swedish and Finnish guidelines. These guidelines were the only two that scored higher than 50% for rigour of development due to their evidence-based approach and transparent reporting of this. They were also the only guidelines, which included a formal ethics review and they both scored highly on stakeholder involvement.

Table 3 shows that the appraisers rated WPATH 7 & 8 "yes (with modifications) / no / no", so majority no and even the minority rejected them as-is. Perhaps it needs rewording - it isn't recommending against, but not recommending for. Void if removed (talk) 22:46, 7 May 2024 (UTC)

I think we should stay within the bounds of the source's conclusions. They chose not to make an overall statement on whether they recommend use of the guidelines or not. I worry that the current article language suggests that they did. We could say something about the individual appraiser's views, but we'd be losing the value of the review by getting into the weeds. Firefangledfeathers (talk / contribs) 01:04, 8 May 2024 (UTC)

Fair, I've removed that. Void if removed (talk) 11:41, 8 May 2024 (UTC)

k Flounder fillet (talk) 20:07, 7 May 2024 (UTC)

I was interpreting this sentence as summarizing the findings in Links and influences between guidelines, but the review still rates SOC 8 rather low and thus even if my interpretation is actually correct and not just another awfully stupid product of my sleep-deprived mind, this quote captures the review's assesment of SOC 8 correctly and my revert was pedantic. Flounder fillet (talk) 20:25, 7 May 2024 (UTC)

Thank you, and yes, weirdly it probably would be more accurate (or at least less debatable) if it wasn't a direct quote! Void if removed (talk) 22:49, 7 May 2024 (UTC)