The why of the WHO

The World Health Organisation launches a hasty and activist-heavy guideline project

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The World Health Organisation’s new guideline project for transgender health has ignored the intense international debate about youth gender medicine and overlooked key reformist experts, according to the prominent American gender clinician Dr Erica Anderson.

“[The WHO] seem to be oblivious to the issues with transgender healthcare, particularly as they are playing out in the developed world,” she told GCN, adding that the agency had failed to draw on the expertise of leading clinicians who come informed by systematic reviews of the evidence base.

Dr Anderson, a “gender-affirming” clinician and past president of the United States Professional Association for Transgender Health, said none of the 21 panel members chosen by the WHO to develop the new guideline seemed qualified to address the issue of social influence as a factor in the explosion of trans and non-binary identities.

“Social media and peer influence have had a huge impact upon the rise in minority sexual and gender identities,” she said.

“Previous research done on prior cohorts of youth cannot account for the rise in such identities. We may need a new biopsychosocial epidemiology in this social media era.” 

The WHO’s panel is due to make crucial decisions about development of the guideline at meetings in Geneva on February 19-21.

One of the expert clinicians overlooked by the WHO, Finland’s Professor Riittakerttu Kaltiala, an early adopter of paediatric gender transition and now a reformist critic, said she was “really worried that the WHO—which should represent responsibility for the health of all people—appears to have committed itself to a fully political initiative promoting treatments based on no evidence.”

“The WHO initiative openly seeks to promote medical gender reassignment, not to find out what is [the quality of the] evidence base, in the best interests particularly of adolescents who, in increasing numbers, problematise their gender.

“Several countries have carried out their own systematic reviews after Finland did so in 2019-2020, and all have concluded that particularly the gender-identity based, body-modifying medical treatments on minors have not been researched appropriately, lack evidence of beneficial effects and have great potential to harm.”

Professor Kaltiala told GCN that the WHO “should seek to balance this overheated and over-politicised field of medicine, not go along with political initiatives. Medicine must be based on science, not on politics.”

On December 18, the WHO announced the guideline project and the final seven members of the panel. Public comment on issues such as conflicts of interest affecting panel members ends on January 8.

A near identical announcement of the WHO project—together with biographies of the first 14 panel members—was issued on June 28, also with a short period for public comment. Both announcements came during holidays in affected parts of the world.

Trans rights activists should “get ahead of the government agenda and the media story” by early intervention in policymaking, according to a notorious 2019 report sponsored by queer lobby IGLYO, the Thomson Reuters media foundation and law firm Dentons.

The report also warns activists to limit “press coverage and exposure” because it seems that “public campaigning has been detrimental to progress, as much of the general public is not well informed about trans issues, and therefore misinterpretation can arise.”

“It has become a throwaway line in some media coverage of transgender care in the United States that even liberal European countries are restricting care for transgender children. But this is a misleading notion. No democracy in Europe has banned, let alone criminalised, care, as many states have done in the US. What has happened is that under increasing pressure from the right, politicians in some countries have begun to limit access to certain kinds of treatment for children…”—Journalist Lydia Polgreen, opinion column, The New York Times, 1 December 2023

“Polgreen is repeating [misinformation in The Times] about what’s motivating European health systems to restrict kids’ access to gender [prescriptions]. It’s not ‘pressure from the right,’ it’s [systematic] reviews of the evidence finding it too weak to justify high risks, e.g., to brain [development], sexual function, fertility.”—Journalist Jennifer Block (author of the BMJ investigation feature on the rise of youth gender dysphoria), tweet, 31 December 2023

Who’s pushing back?

The new WHO guideline is to cover “gender-affirming care, including hormones” and “health policies that support gender-inclusive care”, among other aims such as “legal recognition of self-determined gender identity [known as self-ID].”

The timing and activist language of the WHO announcement, together with the makeup of the panel membership, have mobilised organisations and individuals worried about the international spike in medicalised gender change that disproportionately affects teenage girls who present with atypical gender dysphoria.

A fast-growing petition calls on the WHO to cancel next month’s meetings in Geneva; deal with conflicts of interest and bias affecting the guideline development panel; consider hiring an independent methodologist; and include expert members alert to the potential harm of gender-affirming interventions, as well as detransitioners.

At the time of writing, the petition had more than 5,000 signatures, including many health professionals, as well as detransitioners and LGB groups critical of Queer Theory-driven trans activism. Also signed up is the LGBT Courage Coalition, which was founded by gender clinic whistleblower Jamie Reed and trans man Aaron Kimberly.

“The current panel is highly biased in favour of ‘gender-affirming’ approaches, with an absence of critical perspectives,” says the petition, which was reportedly organised by an informal coalition of those concerned about the safety of the gender-affirming model.

The petition says: “The majority of the [WHO] panel members have expressed strong views in favour of hormonal and surgical interventions for transition, dismissed known and potential risks associated with these interventions, and denigrated psychotherapeutic approaches as [unethical] ‘conversion therapy’.”

“The panel does not include any experts in child and adolescent development or any critics of the affirmation model. Detransitioners and desisters are also excluded. Given the panel’s composition, there is strong reason to believe that the guideline will be similarly biased.

“The final composition of the panel was only announced on December 18 but, according to the WHO, this group will evaluate the evidence and formulate recommendations across a range of topics including healthcare, clinician education, health policies, and laws by February 21.

“To call this a rushed procedure would be a dramatic understatement. Compare this to the process embarked upon by the Cass Review in the UK, for example—a multi-year effort to address the health care needs of just one patient demographic (under-18s) within a single country (England).”

Video: ‘One of the people on that [WHO] panel has said we should be stopping all children’s puberty, we should give all children puberty blockers, so that they can make a decision, when they are old enough, what [gender] they want to be’—Helen Joyce of the group Sex Matters; from the 4:06 time mark

No panacea

A 2023 study by Professor Kaltiala and colleagues using a Finnish healthcare register to follow up patients after gender reassignment delivered results contradicting the familiar claim that the mental health problems of troubled young people will resolve after medical transition.

“The number of people contacting specialised [gender clinics] has increased vastly since the 1990s… and their mean age has become steadily younger,” say the authors of the paper in the journal European Psychiatry.

“Along with this, their needs for psychiatric treatment have increased. Both before and after contacting [the clinic], they present with many more common psychiatric needs than do their matched population controls, even when medical [gender reassignment] interventions are carried out.

“Among people seeking [gender reassignment], psychiatric needs have to be carefully assessed and addressed… This vastly increased pursuit of [gender reassignment] with increases in psychiatric comorbidities warrants cautious assessment of the timeliness of medical [gender reassignment] and of other [non-gender] treatment needs that may be more urgent.”

The WHO’s statement says its “new guideline will provide evidence and implementation guidance on health sector interventions aimed at increasing access and utilisation of quality and respectful health services by trans and gender diverse people [Emphasis added].”

Asked about criticism of the guideline project, a WHO spokesman said “this is a notice phase for the Guideline Development Group [or panel] process, so WHO can solicit feedback”.

“All views will be weighed on the composition of the GDG as part of the guideline development process,” he said.

He said WHO guidelines were “always based on balancing of available evidence, human rights principles, consideration of harms and benefits and inputs of end users and beneficiaries.”

He told GCN that the WHO’s trans health guideline would be “focused on adults only”. He did not reply when asked for documentary proof of this; the WHO announcements simply refer to “people”.

“It is probable that the few cases currently before the courts in the United States, Australia and elsewhere, will be the beginning of a torrent of malpractice suits against doctors and surgeons given the massive increase in children and adolescents attending gender clinics. The WHO guideline therefore must address comprehensively the issues that medical practitioners should consider, and the precautions they should take, to avoid a conclusion by a court that the doctor has engaged in malpractice.”—Queensland University Emeritus Professor of Law Patrick Parkinson, submission to the WHO guideline project, January 2024

Conflicts aplenty

In its statement of concern about the WHO project, the Society for Evidence-based Gender Medicine (SEGM) says: “Since adolescents and young adults are the largest and fastest-growing group of transgender-identified individuals, it is likely that the WHO guidelines will apply to this vulnerable group as a target population.”

SEGM says the language of the WHO announcement “does not appear to be neutral.”

“It states the goal of ‘increasing access and utilisation’ of, presumably, gender-affirmative interventions by ‘trans and gender diverse people,’ and declares the goal of legal recognition of ‘self-determined gender identity’,” SEGM says.

“This suggests that the decision to promote gender transition in the respective societal arenas (medical, policy, legal) has already been made before the group has even met to review and interpret the evidence—a step that must both precede and inform the guideline recommendations.”

SEGM says that “even a cursory review” of the guideline panel membership reveals multiple conflicts of interest, including authorship of past papers that would have to be assessed by the panel; membership or past leadership roles in gender-affirming lobby the World Professional Association for Transgender Health; intellectual bias towards gender affirmation; and a record of strong opinions on issues relevant to the guideline and its evidence base.

As an example, SEGM cites a claim by an Australian member of the panel, Teddy Cook, who is a trans man and former vice-president of the Australian Professional Association for Trans Health (AusPATH). He is also director of LGBTQ+ Community Health for ACON, the former gay rights lobby responsible for the TransHub website.

In 2021, Mr Cook wrote: “The actual side effects of gender-affirming medical care, for those who can access it, include a significantly improved quality of life, significantly better health and wellbeing outcomes, a dramatic decrease in distress, depression and anxiety and a substantial increase of gender euphoria and trans joy... We are not at risk of harm by affirming our gender.”

This is a mere opinion unsupported by the evidence, according to SEGM. (GCN sought comment from ACON and Mr Cook.)

AusPATH has been critical of the Cass review for “questioning an affirmative approach to gender-affirming care”. The AusPATH board says it does “not support ‘exploratory therapy’ which is often used as a euphemism for conversion therapy.”

“[Given the long waiting list, we] prioritise young people who are in the youth forensic system, young people in out-of-home care and young people who are from Aboriginal and Torres Strait Islander communities”—Australian psychiatrist Dr Tram Nguyen, co-head of the Royal Children’s Hospital gender-affirming clinic, media interview, The Age, 30 December 2023

Blots on the escutcheon

Gender-affirming clinician Dr Anderson said she was worried about the WHO making “a new unforced error regarding transgender healthcare” and cited the agency’s “tarnished reputation” after the Covid pandemic and recent scrutiny of its record in the Hamas-controlled Gaza Strip.

“Unlike with Covid and HIV/Aids, we have no virus nor well-documented aetiology [for gender dysphoria],” she told GCN.

“The tools of epidemiology and virology will not yield immediate answers on how to address growing controversies with gender-questioning youth.

“Blistering hot disputes over self-ID [gender] have spilled over into major institutions like schools, prisons, sports, and the healthcare delivery system.”

Dr Anderson said it was the WHO that had “set this in motion [by] moving trans identification, as ‘gender incongruence’, out of psychiatry over to sexual health [in the agency’s diagnostic manual the International Classification of Diseases, ICD-11].”

“While this step is a laudable improvement in depathologising trans identities, the hard work of applying such a change across society and its institutions remains to be done.

“I’m deeply sceptical that, without taking time to think, the WHO can do what needs to be done, let alone win support across the world.

“I try to help gender-questioning people every day. I’ve been concerned about the disputes and controversies for years. Now I’m worried that the WHO will make a mess of it.” 

“In working with minors, the affirmative approach that I’ve always used involves a lot of mental health therapy, assessment, exploration to really individualise the treatment to the specific young person, to involve the parents in the process, to look through a developmental lens, to really understand all the other complex factors, and the medical [option] was a part of it, if and when it was appropriate for that individual child, but in my experience over the years, it wasn’t always the main focus.”—Dr Laura Edwards-Leeper, who was the founding psychologist at the Boston Children’s Hospital gender clinic, The Umbrella Hour podcast interview, December 2023

Missed opportunity

Dr Anderson noted the absence from the WHO guideline project of leading reformists of youth gender care such as the United Kingdom’s Dr Hilary Cass, Finland’s Professor Kaltiala and Sweden’s Professor Mikael Landén; each being guided by systematic reviews of the (weak and uncertain) evidence base.

To this list Dr Anderson added America’s Dr Edwards-Leeper, Dr Scott Leibowitz and herself as clinicians “at the forefront of youth gender issues” but overlooked by the WHO.

In The Washington Post in 2021, Drs Edwards-Leeper and Anderson, both clinical psychologists who use the gender-affirming approach, expressed concern about a surge in cases of rushed medicalisation of troubled minors without careful exploration of their non-gender problems.

That same year, Dr Anderson talked to journalist Abigail Shrier, author of the book Irreversible Damage: The Transgender Craze Seducing Our Daughters, about her concern that today’s teenage female patients might need a different therapeutic response than the classic male patients with onset of gender dysphoria in early childhood.