Not up to standard
The transgender health guild WPATH has issued a messy update to its treatment guideline amid growing pressure and scrutiny
It sounds authoritative and reassuring — the World Professional Association for Transgender Health. If parents are anxious about entrusting a child to gender medicine, they may be told that the clinic follows the gold standard of WPATH’s treatment guideline. And now, after “five years of rigorous scientific effort by more than 120 health care clinical and academic professionals across the globe”, WPATH has released its Standards of Care Version 8 (SOC 8), which “clearly define the treatment of transgender and gender-diverse children and adolescents, including medical interventions such as puberty delaying medications or gender-affirming hormones, and when appropriate, surgical interventions, as medically necessary”.
At least, those are the claims made in WPATH’s media statements. Publicity, politics and the management of competing expectations all overshadow the content of SOC 8. Since the last SOC in 2012, the gender clinic business model has seen rapid global growth with the uptake of puberty blocker drugs and a new patient profile: teenagers, disproportionately female, of the social media epoch. ROGD and detransition are terms of quite recent currency. Abigail Shrier’s book Irreversible Damage is only two years old, and Dr Lisa Littman’s study hypothesising a new, rapid-onset form of gender dysphoria was published just four years ago.
Youth gender clinics today face considerable scrutiny and pressure from civil society groups of parents opposed to medicalisation, from detransitioners on a mission to ensure that others do not repeat their mistakes, from sceptical clinicians and researchers, from a number of European countries with tighter regulation of medicalised gender change for minors, from many U.S. Republican state legislatures seeking to ban — even criminalise — paediatric transition; and inevitably from class action lawyers.
But it gets worse for WPATH. Insiders — leading gender clinicians associated with WPATH and its American franchise USPATH — went public last year with concerns similar to those raised by outsiders. A high-profile American TV program — CBS 60 Minutes — showcased some of the detransitioners said not to exist. And only three months ago, The New York Times, which had seemed such a dependable promoter of an uncritical trans rights narrative, published an article confirming the long-denied reality of expert disagreement about the explosion in youth gender medicine.
In this fraught context, it’s perhaps not surprising that WPATH’s September release of SOC 8 has been attended by chaos and confusion. We have both the 260-page guideline document and a bullet-point “correction”. Those “years of rigorous scientific effort” had culminated in a 2021 draft SOC 8 that dropped the minimum ages for hormonal and surgical treatment. Now, an abrupt correction simply did away with any minimum ages for intervention.
The confusion hasn’t been dispelled by any of the competing explanations offered so far. First, that the publisher jumped the gun before the SOC 8 text had been finalised. Second, that WPATH caved to the radicals who want medicine but not its safeguards. Third, that clinicians would be better shielded from litigation if allowed room to individualise treatment decisions, rather than having to observe age thresholds. Fourth, that some major medical groups had “bristled” at the suggested age restrictions. Fifth, that WPATH lacked consensus. Sixth, that the case for lower age minimums was not strong enough. Seventh, that the correction was the product of a hostile political climate.
None of this is helpful for an organisation that purports to set the international benchmark for gender care. How do others view WPATH? GCN asked various people for their thoughts on SOC 8, focusing on children and adolescents. The resulting commentary, in alphabetical order by surname, has been divided into two parts.
Part 1
Denise Caignon, founder of the pioneering American blog 4thWaveNow:
The 11th-hour ditching of any minimum age recommendations — apart from a semi-buried one advising that the very dangerous phalloplasty be limited to 18-plus — is obviously quite telling.
WPATH officials said it themselves a few days later: they want to help clinicians avoid lawsuits if they deviate from minimum age recommendations by WPATH. This would seem to indicate that they are very well aware of the rising tide of angry detransitioners who are openly discussing suing their gender clinic providers.
All of that said, anyone who has been watching this issue for a few years knows that, particularly in North America, clinicians are doing whatever the hell they want and have been for years. Essentially the new standards of care “affirm“ the ongoing reckless behaviour of the pro-affirmation gender clinicians, who have ignored any guidelines of WPATH or others for a decade or more.
It’s worth keeping in mind that these guidelines are just that — guidelines. There is no regulatory mechanism to enforce them. However, they are frequently cited in lawsuits and media to justify paediatric transition practices. So the guidelines matter. And this latest move brings WPATH in line with the most extreme clinicians (and it must be said, in line with the institutionally captured medical bodies in the U.S. such as the American Academy of Pediatrics and the American Medical Association — and very much out of line with the growing opinion outside North America that paediatric transition needs more restrictions, not fewer.
Excerpt from uncorrected SOC 8: Higher (i.e., more advanced) ages are required for treatments with greater irreversibility, complexity, or both. This approach allows for continued cognitive/emotional maturation that may be required for the adolescent to fully consider and consent to increasingly complex treatments.
Corrected (change in bold): Higher (i.e., more advanced) ages may be required for treatments with greater irreversibility, complexity, or both. This approach allows for continued cognitive/emotional maturation that may be required for the adolescent to fully consider and consent to increasingly complex treatments.
James M. Cantor, Canadian clinical psychologist and researcher, says there is a question central to policy-making but not discussed:
How often is transition just unnecessary? That is, what if kids receiving transition services do well, but kids receiving psychotherapy do just as well? There’s be no reason to risk or sacrifice fertility, sexual function, money, etc. These interventions do not have the same risk/benefit ratio (or cost). The burden of proof lies with the medical path addressing gender, not the psychotherapy path addressing dysphoria. The ethical default is psychotherapy until proven otherwise, not medical intervention until proven otherwise.
SOC 8: A chapter dedicated to transgender and gender diverse adolescents, distinct from the child chapter, has been created for this 8th edition of the Standards of Care given 1) the exponential growth in adolescent referral rates; 2) the increased number of studies specific to adolescent gender diversity-related care; and 3) the unique developmental and gender-affirming care issues of this age group.
Roberto D’Angelo, director of the Society for Evidence-based Gender Medicine:
Rigorous systematic reviews of evidence continue to show that the benefits of treating gender dysphoria with hormonal and surgical interventions are highly uncertain. In contrast, the risks are much better understood. If puberty is blocked early and followed by cross-sex hormones, sterility ensues. Many other risks are emerging including risks to bone and brain development as well as a compromised sexual function, cardiovascular health, and many other physiological functions.
SEGM will be reviewing the WPATH SOC 8 guidelines in the coming weeks to assess the quality of these recommendations and the extent to which they provide accurate and balanced information to reflect the potential benefits, risks and uncertainty inherent in medicalising rapidly growing numbers of youth who express feelings of gender diversity and wish to undergo gender transition.
SOC 8: Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead.
SOC 8: … taken as a whole, the data show early medical intervention — as part of broader combined assessment and treatment approaches focused on gender dysphoria and general well-being — can be effective and helpful for many transgender adolescents seeking these treatments.
Oliver Davies, Australian detransitioner:
[On SOC 8 attributing detransition to “external factors, such as stigma and lack of social support” …] Unless I'm some kind of incredible edge case, my experience and that of people I know is that outright transphobia is quite rare — including in regional Australia. I never experienced transphobia [when I was identifying as a woman]. Have I heard anecdotally about someone detransitioning because of transphobia? I'm not saying it doesn't happen, but [I’ve seen] no structural or socially broad transphobia. I can't imagine someone in Australia in 2022 feeling socially pressured [to detransition] except in rare, extreme circumstances. Once they've managed to transition, any bridges have already been burned — and they’ll have started a new life. [The SOC 8 line on detransition] doesn't make any sense to me.
[The explanations for detransition] seem to come down broadly to two groups. One group of people, perhaps someone like me, for whom [medical transition] was simply never going to be a beneficial pathway or treatment. And then another set of people who perhaps do have gender dysphoria, but were dreadfully mistreated by the healthcare system in the sense that perhaps their surgery was botched. Or they get down to the end of the road and realise, ‘Everyone I went to, seeking support, they just see everything through the lens of being trans, everyone completely ignores all the other red flags’.
I think this speaks to the one-dimensional approach to trans healthcare in the affirmative model, that refuses to accept gender dysphoria as a pathology. That contributes to bad outcomes for trans people — the very statistics that are thrown around to justify the push to remove safeguards.
To me right now, it's not really about detransitioners. My greatest concern is that children who will not benefit from this [medical transition] are being led down this path. Gender dysphoria is now self-diagnosed and any family doctor — including doctors with no training or specialisation in this area — can initiate puberty blockers or hormones, as long as the parents agree.
I’m not an expert, but my belief is that [at WPATH], they're essentially in damage control mode. They're a proxy for an enormous and profitable industry, their incentives aren't connected to patient outcomes, and they seem to operate in a world of their own.
SOC 8: While little research has been conducted to systematically examine variables that correlate with a [trans] adult’s decision to halt a transition process or to detransition, a recent study found the vast majority of [trans] people who opted to detransition did so due to external factors, such as stigma and lack of social support and not because of changes in gender identity (Turban, King et al., 2021).
Bev Jackson, co-founder of LGB Alliance UK:
LGB Alliance is horrified by the latest version of the standards of care issued by WPATH, assumed by many to be an expert body on “transgender healthcare”. This is an issue of grave concern to us, because of the increasing awareness that LGB teens, especially lesbians, frequently mistake their sexual orientation for a “gender identity” issue. They then seek hormones and surgery in an attempt to relieve their distress. In many cases they come to regret these interventions — but not until some 8 to 10 years later.
The new WPATH standards of care are appalling. Besides the extraordinary inclusion of a chapter on “eunuchs” under the “gender diverse umbrella”, there are numerous alarming details. Healthcare professionals are recommended to prescribe hormone treatment to children without parental involvement if such involvement would be “harmful or unnecessary”.
Worst of all, perhaps: the series of “corrections” issued after publication remove all recommended minimum age limits for drugs and surgeries.
The evidence provided by detransitioners and the warnings by clinicians increase day by day. Many countries now advise more holistic care and a greater focus on psychotherapy for children suffering from gender dysphoria.
It is unconscionable that WPATH sweeps all this aside and is placing even more gender non-conforming children at risk.
SOC 8: For a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider (Kornienko et al., 2016). However, caution must be taken to avoid assuming these phenomena occur prematurely in an individual adolescent while relying on information from datasets that may have been ascertained with potential sampling bias (Bauer et al., 2022; WPATH, 2018). It is important to consider the benefits that social connectedness may have for youth who are linked with supportive people (Tuzun et al., 2022).
Video: On the known and unknown risks of puberty blocker drugs
Writing from elsewhere, a selection of other commentary on SOC 8
The [WPATH] document does try to find some middle ground. It accepts that other mental-health issues must be dealt with. But it insists that a systematic review of evidence of outcomes in youth transitioning, called for by critics, is not possible, even though Britain did one (the findings contributed to the decision to close the Tavistock youth clinic that also promoted gender affirmation) — The Economist magazine
The final SOC 8 was expected to lower the minimum age for prescribing testosterone or oestrogen from 16 (in version 7) to 14 and to set minimum recommended ages of 15 for breast removal, 16 for breast augmentation and facial surgeries, 17 for hysterectomy, vaginoplasty, or removal of testicles, and 18 for phalloplasty. The deletion of the age recommendations seemed to have happened at a late stage and after increased attention in social media on gender-related surgery among adolescents — The BMJ
The simplistic message — to prioritise the child’s “established self-knowledge”, even above their parents — is in my view naïve and unwise. Children believe all sorts of things that adults tell them. In more recent times, the influence of social media has grown to the extent that parents may be totally unaware of the adults who are doing the influencing — Debbie Hayton, journalist, teacher and transsexual
The guidelines explicitly state that therapy or counselling should “never be mandatory” before prescribing irreversible medication or surgery, including for children. Therapeutic professionals are told that they must not impose their own narratives or preconceptions, yet are also told that they must be “gender affirming”. These principles are fundamentally incompatible — James Esses of Thoughtful Therapists
Transgender patients carry all the risk of transition. Gender clinicians may prescribe hormones, may enable surgery. Parents may sign off on all of this. But it is the young person whose body gets changed who has to live with it forever. Money can't fix anything. There is no practical accountability mechanism for gender clinicians who provide poor care. WPATH SOC8 removes any of the inadequate protections that previously existed. WPATH is rightly regarded as an enemy of patient welfare. [American] transgender activists have been arguing for years that there are no surgeries happening on minors, despite plenty of evidence to the contrary. Since these activists already believe no surgery is happening, enacting policy to ensure this should instigate no objection. It is necessary for regulators to get involved. [U.S.] state legislatures have this legal responsibility. This can also be done at a national level. It is necessary to ban “gender affirming” surgeries for anyone under the age of 18. This is the only option available currently to protect vulnerable youth — Corinna Cohn, podcaster and transsexual
Where would we all be without you Bernard? Thank-you for your tireless, ongoing incredible work.