Standard variation

WPATH's treatment guideline cannot justify the dogmatic practice of 'gender-affirming care'

Photo by Kyle on Unsplash

Sandra Pertot*

Scott Leibowitz, the co-lead author of the adolescents chapter for the latest standards of care (SOC-8) from the World Professional Association for Transgender Health (WPATH), has described SOC-8 as “consensus- and evidence-informed clinical guidelines to help distinguish those who would benefit from treatment versus those who would not.”

This claim is starkly at odds with reality. Disagreement about the assessment and management of gender-questioning people has led to the most toxic and divisive conflict in health services that I have experienced in 50 years as a clinical psychologist.

Medical and surgical interventions for those who wish to live as the other gender have always been controversial. However, a major difference between WPATH’s current standards of care and the very first set of standards (SOC-1) is that the early authors were aware of and open about the difficulties inherent in helping gender-questioning people.

Those first standards, published in 1979, cautioned that hormonal and surgical “sex reassignment” was extensive, invasive and not readily reversible; therefore, it should not be performed on an elective basis; it could be sought by people experiencing short-termed delusions or beliefs which might not persist; and there were known cases of regret.

These strong words of caution in SOC-1 were repeated in standards published by the organisation now known as WPATH in 1980, 1981 and 1994—but this prudence was removed thereafter. Children and adolescents were first included in SOC-4 (1994).  

In my own practice in the 1990s, I saw a man who had been on cross-sex hormone therapy for some years, had lived as a woman and was waiting for what was known then as sex-reassignment surgery. However, he formed a relationship with a woman and decided he wanted to remain a man, and consulted me because he was having sexual difficulties due to the hormone therapy. This taught me that sometimes, despite strong convictions when clients began seeking medical and surgical treatment, some would come to realise it is a mistake.  

So how did we get where we are today, when any health professional who expresses concern about “gender-affirming care” (GAC) is likely to be disciplined in some way, or even lose their job?

When health professionals first offered what is now known as “gender-affirming” medical and surgical treatment last century, gender dysphoria was considered a mental disorder. However, in the early 2000s, there was a movement to depathologise those whose “gender identity” is different to their biological sex. This began in SOC-7 (2012) with a shift of emphasis in requirements for treatment eligibility. Instead of lengthy psychological therapy and an extended period of living as the preferred gender, only a gender assessment covering the history of their gender dysphoria was required.

There was also a shift in language from “gender identity disorder” to gender dysphoria in the 5^th edition of American psychiatry’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2012), as well as its removal from the chapter on sexual dysfunctions and paraphilias.

Nevertheless, the authors of SOC-7 also stated that the health professional’s role included “making reasonably sure that the gender dysphoria is not secondary to or better accounted for by other diagnoses.” Letters of recommendation were required from a mental health professional supporting hormonal or surgical intervention before any treatment was initiated.

This requirement of assessment and approval by a mental health professional is regarded as “gatekeeping” by some members of the trans community. A colleague explained it to me in these terms—“Trans people shouldn’t have to prove they are trans”, and therefore “our role is not to gatekeep someone’s gender through the logic of diagnosis”. As such, gatekeeping is said to be demeaning and unnecessary. My colleague told me that “people should have control over their own bodies [and] providers should respect the autonomy of people with mental illness to make their own decisions, unless lethality is at issue”.

In 2013, Hidalgo et al, a group of clinicians who worked with gender-questioning young people in the US, outlined what they called the “Gender-Affirmative Model” based on the following premises—

“Gender variations are not disorders.

“Gender presentations are diverse and varied across cultures.

“Gender involves an interweaving of biology, development and socialisation, with all three bearing on any individual’s gender self.

“Gender may be fluid and is not binary, both at a particular time and if and when it changes within an individual across time.

“If there is pathology, it more often stems from cultural reactions (e.g., transphobia, homophobia, sexism) rather than from within the child.”

In 2018, an argument was made for “informed consent” to be sufficient for adults to access cross-sex hormone treatment with no requirement for a mental health assessment or a diagnosis of gender dysphoria. As an Australian general practitioner (GP or family doctor) put it—

“Under an informed consent model of care, the treating GP is the main care provider. There is an emphasis on self-determination, patient-centred care and mental health support. Mental health support can be provided by a counsellor, GP, psychologist, psychiatrist or peer worker depending on the patient’s needs.”

Private providers in Australia such as Equinox and Austin Health offer medical care under the informed consent model. A mental health assessment is not required to receive hormone for clients as long as they do not have “significant mental health issues impacting their ability to provide informed consent…”

GAC is now the accepted protocol in WPATH’s latest standards, which says—

“Gender affirmation is used as a term in lieu of transition (as in medical gender-affirmation) or can be used as an adjective (as in gender-affirming care).

“The goal of gender-affirming care is to partner with transgender and gender-diverse (TGD) people to holistically address their social, mental, and medical health needs and well-being while respectfully affirming their gender identity.

“It is rare for gender-questioning clients to have a condition that may be mistaken for gender incongruence or to have another reason for seeking treatment aside from the alleviation of gender incongruence.”

It is a significant departure from accepted clinical practice to assume, without a comprehensive assessment, a specific outcome for a complex set of signs and symptoms. For this reason, a new narrative to support the model of GAC with informed consent was developed, and this is found in SOC-8.

In contrast to SOC-7, WPATH’s current standards strongly emphasise the risk of suicide, which is weaponised by trans activists and GAC health professionals with the unethical line, “Do you want a dead cis [or non-trans] child or a live trans child?” to convince reluctant parents to agree to treatment. SOC-8 repeatedly stresses that GAC is “medically necessary” and, for the first time in the history of WPATH standards, describes it as “lifesaving”.

This is the now common narrative, as shown by the Australian website TransHub—

“Gatekeeping happens when health professionals place unnecessary and unfair hurdles in the path of affirmative care, and require trans and gender diverse patients to prove who we are and that we really want or need access to medically affirming care.

“For those who seek it, gender-affirming medical interventions can be a critically important part of how we affirm our gender. Interventions are not only medically necessary, but lifesaving.

“All gender-affirming care must be inclusive, self-determined and rights-based. Barriers to timely, culturally safe, and accessible medical gender affirmation can result in tragic consequences.

“You have a right to safe and considered affirmative care, free from experiences of gatekeeping or disrespect.”

While children and adolescents under 18 cannot use the informed care model, the gender-affirming instruction is that decisions about health care, including social transition, must be “led by the child”.

SOC-8: sound guidelines or just suggestions?

The following pointers in SOC-8 seem to support good clinical practice. Unfortunately, the final statement of the last paragraph undermines this advice and allows for significant variation in care—

“An individual’s gender identity is an internal identification and experience. The role of the assessor is… to offer information about gender-affirming medical and/or surgical treatments (GAMSTs), to support the TGD person in considering the effects/risks of GAMSTs, and to assess if the TGD person has the capacity to understand the treatment being offered and if the treatment is likely to be of benefit.

“We recommend health care professionals working with gender-diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.

“As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person (Note: emphasis added).”

Is gender “innate and immutable”?

A core concept of GAC is that the gender-questioning person knows who they are, and to suggest a person might be influenced by social factors is insulting. Yet there are several references throughout SOC-8 which contradict this—

“There is ample reason to suppose, apart from biological factors, psychosocial factors are also involved in gender identity.

“For a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider.

“Gender trajectories in prepubescent children cannot be predicted and may evolve over time.

“A child’s gender identity and expressions may evolve over time.

“Some TGD adults may also experience a change in gender identity over time so that their needs for medical treatment evolve.”

It isn’t clear, then, how a clinician can make a safe diagnosis of gender dysphoria based on the current presentation of the client. How is social influence to be assessed with individual clients? If the clinician has doubts about the permanence of a diagnosis of gender dysphoria, how does this affect treatment considerations?

Assessment

There are similar mixed messages in SOC-8 about the type and purpose of an assessment. GAC requires an assessment, but its nature is the subject of debate in health services.

SOC-8 refers to the need for a “comprehensive, diagnostic, biopsychosocial assessment”, especially for adolescents, which if carried out correctly should identify any co-morbid mental health problems. It is generally agreed that gender-questioning people have a higher prevalence of mental health problems—including depression, anxiety, suicidality, autism and other conditions—compared to the general population.

The recommended assessment also includes an account of the development of symptoms of gender dysphoria, how family and friends have reacted to the person’s desire to transition and an assessment of any emotional distress due to the stigma associated with being trans.

Then the concept of “minority stress” is introduced—

“Intersectional forms of discrimination, social marginalization, and hate crimes against TGD people lead to minority stress. Minority stress is associated with mental health disparities exemplified by increased rates of depression, suicidality, and non-suicidal self-injuries than rates in cisgender populations.”

Minority stress, with its emphasis on the plight of a trans person in a transphobic society, is a concept referred to frequently in SOC-8 to counter the suggestion that exposure to the positive online portrayal of trans identity may influence a person with mental health problems to come to believe that transitioning to the other gender will resolve their problems.

SOC-8 does advise that a mental health assessment be carried out by a health care provider “with some expertise in mental health” who can refer to a mental health professional (MHP) “if needed”. However, SOC-8 stipulates that “rather than impose their own narratives or preconceptions, MHPs should assist their clients in determining their own paths”, because—

“There is no evidence to suggest a benefit of withholding GAMSTs from TGD people who have gender incongruence simply on the basis that they have a mental health or neuro-developmental condition.”

To summarise the SOC-8 position on mental health concerns—a person seeking GAC is likely to have significant mental health problems but, ignoring all other possibilities, we should conclude these are most likely caused by untreated gender dysphoria, so mental health problems should not be a reason to withhold GAC.

Rapid Onset Gender Dysphoria (ROGD)

Dr Lisa Littman’s theory that some young people come to the sudden belief they are trans after being influenced by social factors in their friendship group or social media triggered a swift reaction from GAC health professionals.

A 2018 WPATH statement says the organisation “urges restraint from the use of any term [such as ROGD]—whether or not formally recognized as a medical entity—to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options…”

However, the authors of the 2022 SOC-8 document only recommend medical treatment when the experience of gender incongruence is “marked and sustained”. They say that the necessary “stability of gender identity” will be shown by its “persistence”, “length and consistency”—

“An abrupt or superficial change in gender identity or lack of persistence is insufficient to initiate gender-affirming treatments, and further assessment is recommended. In such circumstances, ongoing assessment is helpful to ensure the consistency and persistence of gender incongruence before GAMSTs are initiated.”

Maybe Dr Littman is on to something after all.

Concerned parents

Yet parents’ concerns, according to SOC-8, are to be overridden—

“Some parents may present with unsupportive or antagonistic beliefs about TGD identities, clinical gender care or both. Such unsupportive perspectives are an important therapeutic target for families.”

Regret/detransition

While the authors of SOC-8 insist that regret and detransition are rare, for the first time WPATH acknowledges the need for the development of health care services for those who wish to return to live as the original gender. The standards also state that the possibility of regret should be discussed with gender-questioning adolescents prior to initiating any treatment.

Significantly, the authors of SOC-8 acknowledge that little research has been conducted to systematically examine variables that correlate with poor or worsened biological, psychological, or social conditions following transition.

How, then, can Dr Leibowitz, as a contributing authors of SOC-8, make the claim that there is evidence in the standards to aid a clinician to identify those gender-questioning people unlikely to benefit from GAC?

SOC-8 in practice

Given that SOC-8 contains so many contradictions and deficiencies, it is not possible to justify the rigid application of gender-affirming treatment in clinical practice. However, the aggressive policy of silencing any critics in health, education or organisations has given WPATH and its allies a clear field to demand adherence to GAC.

The continual downplaying of regret and detransition belies the reality that the current requirements for access to GAC are significantly more broad and loosely defined compared to earlier WPATH standards of care. As such, it should be expected that the regret and detransition rate will be higher than when tighter criteria were in place. It seems inconceivable that modern gender specialists were unaware of the risks of relaxing the requirements for access to GAC.

Never in my decades working in health care have I experienced such an arrogant refusal to acknowledge flaws in a health policy and to dismiss any adverse outcomes as rare and not worthy of consideration. Accepted best practice requires that all health policies must be open to review and revision. Adverse outcomes should be noted in order to research and identify any red flags that might indicate a poor outcome for future clients. This opportunity to develop a clearer risk profile of those who would or would not benefit from GAC has been squandered over years because of the hubris of those committed to the GAC policy.

Detransitioners, concerned and loving parents and health professionals who have acted in good faith in questioning GAC all seem to be acceptable collateral damage for… what? It is difficult to identify the main factor driving such fervour about a health policy. Genuine concern for trans people? Maybe, but I doubt it is that simple.

Health profession responsibility

The authors of SOC-8 refer to the importance of individualised care for each client, as well as the freedom for each health provider to adapt and develop their individual approach to gender-questioning clients.

Given this, there should be allowance for significant departure from the rigid prescription of GAC that seems to have taken hold in health services across the western world. In theory, this would mean that individual clinicians who express concern about GAC should be given support to state their concerns.

Instead, it seems that this permission for a GAC health professional to do their own thing has led to a weakening of the performance of accepted clinical practice. For example, some detransitioners describe being given access to medical treatment without a comprehensive mental health assessment to determine if their stated gender dysphoria is an attempt to find a solution to pre-existing mental health problems. This cannot be justified as ethical and responsible care.

What I find disturbing is that GAC health professionals are given permission to set their own “individualised care.” For example, the authors of SOC-8 made a last-minute decision to abandon minimum age thresholds for most medical interventions. Again, there is the internal contradiction in what is supposed to be a standard of care: we don’t really know what we are doing, but it is okay to do it at any age (phalloplasty being the only exception).

What further adds to my concerns about the underlying motives of the WPATH authors is the quiet inclusion of “eunuch” as a valid gender identity—

“Eunuch individuals are those assigned male at birth [who] wish to eliminate masculine physical features, masculine genitals or genital functioning.

“As such, eunuch individuals are gender non-conforming individuals who have needs requiring medically necessary gender-affirming care.”

My question to all GAC health professionals—how would you respond to a male requesting all his masculine features to be removed? Would you support his aims in the same way you support transgender clients’ requests for genital reassignment and/or mastectomy? Would you want certain prerequisites to be met? What might lead you to deny his requests?

Now think about another identity, a person with Body Integrity Identity Disorder—

“[This term] describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord.”

Now think about how you came to the view that for any client who says they are trans the right and only way to proceed is medical and possibly surgical intervention.

Do you believe that supporting gender-questioning people to transition is the same as supporting sexuality-questioning clients? If so, take a moment to think about the differences between these two situations: one involves medical and often surgical treatment, the other doesn’t. Linking these two issues is a deliberate strategy of trans lobby groups, as shown by the notorious Dentons report on trans activist strategy.

I became involved in questioning GAC as it is currently practised because it does not identify any risk profile for a client who may not benefit from medical or surgical treatment and may in fact be harmed by it. My clinical stance has been reinforced by hearing the histories on detransitioners. My clinical experience over decades tells me that some gender-questioning clients who are transgender are likely to benefit from GAC. In this current context, however, I would be hesitant to support any client to socially or medically transition until they were adult.

Conclusion

Health professionals undertake rigorous education and training to meet accreditation criteria. Yet unfortunately the profession has form for giving unquestioning support to bad policy. Psychiatric diagnostic controversies, fads and epidemics are all too common. In child and adolescent psychiatry, McClellan and Werry (2003) noted—

“[We] still suffer faddish waves of unsupportable treatments and idiosyncratic practices; caution and humility are indicated when assessing our standards of care.”

Some of the fad diagnoses and treatments, which were seen as progressive at their height and as scandals after they had run their course, include:

The 1930s-1950s epidemic of frontal lobotomies that began for aggression in patients with schizophrenia but later were to include even children with oppositional behaviour;

The multiple-personality disorder diagnostic epidemic of the 1980s;

The “Satanic panic” epidemic of alleged day-care centres’ ritual abuse of young children in the 1980s to early 1990s;

Deep sleep therapy in Australia’s state of NSW

As the number of detransitioners increases and their stories are finally investigated, it seems likely that gender-affirming care will ultimately be added to that list.

*Dr Sandra Pertot recently retired after 50 years of clinical practice specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity