Blowback

As advocates for transitioning minors, medical societies may end up on trial themselves

Photo by Sasun Bughdaryan on Unsplash

The World Professional Association for Transgender Health (WPATH) and American medical societies have sacrificed child safety and standards of scientific evidence in pursuit of fashionable causes and financial self-interest.

This is the charge levelled in a blistering court brief filed last week by Alabama’s Attorney-General Steve Marshall and 15 other Republican states in defence of Missouri’s law restricting medicalised gender change for minors. A county court judge is to decide whether the law—under challenge from transgender-identifying plaintiffs—is put on hold or goes into effect as scheduled on August 28.

“While medical organizations are certainly capable of establishing true, evidence-based standards of care [for the distress of gender dysphoria], they have utterly failed to act responsibly when it comes to pediatric gender transition procedures,” the amicus brief says.

WPATH, the Endocrine Society and the American Academy of Pediatrics (AAP) are central to the debate about the safety of youth gender clinics because their endorsement is regularly invoked—in the absence of a sound evidence base—to justify “gender-affirming” medical interventions such as puberty blocker drugs and synthetic cross-sex hormones for minors.

This in turn is provoking a more intense counter-attack on the trustworthiness of the gender-affirming treatment guidelines and policy statements issued by medical societies, who have put their reputations on the line amid political polarisation.

In Alabama and Florida, state administrations fighting challenges to laws shutting down youth gender medicine have retaliated by issuing subpoenas to expose in court the nature of the internal processes that led to adoption of contentious treatment policy documents.

These preliminary skirmishes may foreshadow potential lines of attack on medical societies enlisted in the trans rights cause, should a test case reach the Supreme Court of the United States.

“The WPATH standards of care for the health of transgender and gender-diverse (TGD) people, now in its 8th version (SOC8), is the foremost evidence-based guideline for the provision of TGD healthcare. SOC8 is based on the best available science with input from over 100 global medical professionals and experts and represents best-practice guidelines for the provision of gender-affirming healthcare. Gender-affirming interventions are based on decades of clinical experience and research and are not considered experimental. Gender-affirming hormone therapy is a component of widely accepted medically necessary care for TGD people.”—WPATH, statement denouncing Missouri’s emergency restrictions on youth gender medicine, March 2023

Who’s in charge?

Last week’s multi-state intervention in favour of Missouri’s “Save Adolescents from Experimentation” Act protests that medical associations are being touted “as the real regulators [of healthcare], authoring standards that no mere state could contradict.”

According to the Alabama-led brief, the trans-identifying plaintiffs’ argument would constitutionally entrench WPATH’s “shoddy standards.”

The brief says that while others debate how best to help children with gender dysphoria, WPATH has “taken its gender ideology to the extreme and included in its latest standards of care [SOC8] an entire chapter on self-identified eunuchs.

“In addition to advocating castration as ‘medically necessary gender-affirming care’ for males whose ‘gender identity’ is ‘eunuch,’ WPATH recently removed most minimum-age requirements for gender-modification procedures from its standards of care.

“According to the lead author of the [SOC8] chapter on children, WPATH dropped the age requirements to ‘bridge th[e] considerations’ regarding the need for insurance coverage [of treatment] with the desire to ensure that doctors would not be held liable for malpractice if they deviated from the standards.

“Just as with eunuchs, WPATH’s standards consider sterilizing gender-modification procedures to be medically necessary ‘gender-affirming care’ for minors suffering from gender dysphoria. This is the stuff of nightmares or farce, not constitutional law.”

The brief says that by supporting WPATH’s radical treatment guideline, the American Medical Association has failed to “use their institutional goodwill, built up over time, to be the voice of reason and put the safety of children first.”

It says WPATH has “suppressed dissent” from the dogmatic gender-affirming model, and “tried to cancel nearly every researcher that has looked at rapid-onset gender dysphoria” (the hypothesis that social influence helps explain the unprecedented surge in trans declarations chiefly by teenage females).

As for the American medical associations lined up in support of gender-affirming treatments, the brief says they are “interest groups, with a strong financial interest in our capitalistic economy to promote the procedures their members make a living by providing.”

At the same time, these “American medical organizations have become increasingly ‘performative,’ treated by their leaders as platforms for advancing the current moment’s cause célèbre.

“Add to this a replication crisis in scientific literature and the ability of researchers to use statistics to make findings appear significant when they are not, and it is no wonder that medical organizations find it easier to just go with the zeitgeist.

“Science is hard, and there is no reward in the current climate for any organization that questions the safety and efficacy of using sterilizing gender-modification procedures on children.”

The multi-state brief challenges the mantra that “the science is settled” in favour of the gender-affirming treatment model.

That model promotes early social transition, potentially locking in gender dysphoria, and puberty blockers almost always followed by cross-sex hormones meant to be taken lifelong—a combination expected to render patients sterile and for males, incapable of orgasm.

“[England’s National Health Service, the NHS] recommends that [puberty blockers] for children and young people with gender incongruence [a sense of mismatch between body and identity] should only be accessed through research. [The] National Institute for Health and Care Excellence (NICE) was commissioned [in 2020] to review the published evidence.

“Overall, there was no statistically significant difference in gender incongruence, mental health, body image and psychosocial functioning in children and adolescents treated with [puberty blockers]. [The NHS] has concluded that there is not enough evidence to support the safety, clinical effectiveness and cost effectiveness of [puberty blockers] to make the treatment routinely available at this time.

“NHS England commissions treatment based on evidence of clinical effectiveness, cost effectiveness and safety. WPATH standards of care do not determine clinical commissioning decisions for the NHS.”—NHS England, statement, 3 August 2023

Watch and wait

The brief in the Missouri case says: “In recent years, medical authorities in the United Kingdom, Finland, Sweden, and Norway have all looked at the evidence and determined that [medicalised gender change for minors is] in fact experimental.

“[American] states have every reason to wait for the results of the experiments to come in before allowing children to be sterilized… the medical interest groups [that the trans-identifying plaintiffs in the Missouri case] rely on are biased participants, not neutral arbiters of science. 

“Plaintiffs [litigating against Missouri] entirely discount the European experience, suggesting that no European regulator qualifies as a ‘reputable medical association.’

“But how can pediatric treatments that several European countries treat as experimental be definitively ‘neither harmful nor experimental’ for children in Missouri?

“Such treatments [as puberty blockers and cross-sex hormones] stunt children’s pubertal and mental development, lower their bone density, and gamble away their ability to have children as adults. 

“While healthcare authorities in Europe have curbed access to pediatric gender transition procedures, American medical organizations have run in the opposite direction: advocating unfettered access to transitioning treatments while quashing [their own] members’ calls to review the evidence.”

Apart from Europe’s evidence-based shift to caution, the brief in the Missouri case also cites recent reporting and commentary in the British Medical Journal and the Wall Street Journal potentially damaging to the authority of WPATH, the Endocrine Society, the AAP and their treatment policy documents.

Other recent developments illustrating the potential vulnerability of medical societies include—

In litigation over Oklahoma’s law banning paediatric gender medicine for minors, the medical watchdog group Do No Harm in June highlighted the inconsistency of the American Academy of Child & Adolescent Psychiatry, noting its belief that adolescents can give informed consent “when it comes to the permanent and lifelong risks of experimental gender medicine, such as sterilization”. However, Do No Harm said the academy took quite a different position in the context of lifetime prison sentences for minors, where it protested that adolescents “are more likely than adults to engage in risky, impulsive, and sensation-seeking behavior … overvalue short-term benefits and rewards, and are less capable of controlling their impulses … [and] are also more emotionally volatile and susceptible to stress and peer influences.”

In March 2023, U.S. District Court Judge Liles C. Burke ruled that WPATH’s guidelines were “part and parcel” of the case brought by plaintiffs against Alabama’s law restricting paediatric transition. For this reason, WPATH could not block the state’s subpoena seeking documents about the guideline process, including the association’s “consideration, if any, of the U.K.’s NICE literature reviews [declaring the evidence base to be very uncertain, and] the Swedish and French statements regarding [the risks of] transitioning care for minors.” Judge Burke said that allowing WPATH to withhold such information “would, in essence, amount to acceptance of WPATH’s standards as ‘established, evidence-based clinical guidelines’ on WPATH’s word alone, and without further inquiry.”

In a challenge to Florida’s curbs on youth gender medicine, the Endocrine Society, WPATH and the AAP also resisted state subpoenas seeking to reveal the inner workings that led to their treatment advice documents. But District Court Judge Carl J. Nichols agreed with Florida in March that this information “goes to the heart of the lawsuit”, being the question “whether, based on current medical knowledge, the state’s determination that [certain] treatments [for gender dysphoria] are experimental is reasonable.” The judge pointed out that the plaintiffs challenging Florida’s law “lean heavily” on the positions taken by these medical associations. He said it was “also understandable that the state would try to defend the reasonableness of its position by seeking information that goes to the rigor of the process by which the guidelines and policy positions were adopted.”

Note: GCN has sought comment from WPATH, the AAP, the Endocrine Society and the American Academy of Child & Adolescent Psychiatry