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Low standards

Institutions should reject WPATH advice

The World Professional Association for Transgender Health (WPATH) claims to be a non-profit, interdisciplinary professional and educational organisation devoted to transgender health. It is seemingly credible, and UK clinicians — both NHS and private — proudly trumpet their links to it. 

We should therefore take notice when WPATH publishes updated Standards of Care “for the Health of Transgender and Gender Diverse People”. Last week, WPATH released Version 8. My concerns began with the press release.

The Standards of Care 8 represents the most comprehensive set of guidelines ever produced to assist health care professionals around the world in support of transgender and gender diverse adults, adolescents, and children who are taking steps to live their lives authentically.


What does it mean to be gender diverse? Why include adolescents and children? How can a life not be authentic? But when the list of authors includes Susie Green — Chief Executive Officer of Mermaids — it is perhaps unsurprising when SOC8 uses the language of activists.

The chapters on adolescents and children were particularly worrying. Behaviour was shackled with identity as WPATH stepped far beyond the worthy observation that girls can be more masculine in their behaviour and expressions, and boys can be more feminine. 

We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent.

— WPATH SOC8 recommendation 6.4 [my emphasis]

After warning about “reparative and conversion therapy” — rather than recommending exploratory psychotherapy? — WPATH launched into physical and chemical interventions:

We suggest health care professionals provide transgender and gender diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.

— WPATH SOC8 recommendation 6.6

Let’s be clear, binding and tucking are restrictive practices. A study of 1800 women who bound their breasts by Peitzmeter et al (2017) found that over 97% reported at least one of 28 negative outcomes. Pain was the most common, but some reported muscle wasting, rib fractures and scarring.

There is little research about the potential harms of genital tucking for boys, so for all the talk of reviewing risks, the long term outcomes are largely unknown. One case study of a 27-year-old-transwoman did find that tucking had resulted in oligospermia — an abnormally low sperm count — affecting fertility.

But WPATH appears to be less concerned about the health of the body than affirming a gender identity. For girls who are distressed by the onset of menstruation — something experienced by young women throughout history — a diagnosis of “gender incongruence” can lead straight to medical intervention.

“We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.”

The original text of SOC8 did at least include minimum ages for hormone treatment and surgical interventions — 14 for cross-sex hormones, 15 for a mastectomy, 16 for breast augmentation and 17 for gender reassignment surgery — but even those meagre protections were removed in a subsequent correction.

Stella O’Malley — director of Genspect, an international alliance of professionals, parent groups and others — has called that correction “a significant and ideological change of gear”. O’Malley told The Critic that, “the decision of WPATH to remove the minimum age requirements for irreversible surgical procedures such as double mastectomies and vaginoplasty demonstrates that WPATH is an activist-led organisation that has little concern for safety, caution or clinical care”.

Instead, the concern seems to be for clinicians. As evolutionary biologist Colin Wright revealed, “Amy Tishelman, lead author of the Child chapter in WPATH’s new guidelines, admitted that minimum age recommendations for ‘gender-affirming’ hormones and surgeries were removed so that practitioners could not ‘be sued because they weren’t following exactly what we said’.”

The so-called Standards of Care recommends puberty blockers when “the adolescent has reached tanner stage 2,” that is the onset of puberty — as early as 8 for girls and 10 for boys. SOC8 recommendation 6.12g then lists a smorgasbord of surgical interventions that can then follow, “including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery”.

For younger children, psychotherapy is recommended but the focus is affirmation. Recommendation 7.12 is explicit, “We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity.” The child is deemed to know best. WPATH draws on a paper by Ehrensaft et al that suggests, 

A child’s social transition (and gender as well) may evolve over time and is not necessarily static, but best reflects the cross-section of the child’s established self-knowledge of their present gender identity and desired actions to express that identity.

— WPATH SOC8 Statement 7.12

Diane Ehrensaft — lead author on that paper — is also a co-author of SOC8 itself, along with Susie Green and the rest. 

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.

After the chapters on adolescents and children, the Standards of Care explores non-binary identities — once again recommending medical and surgical interventions (SOC8 8.2, 8.3) — before considering eunuchs. 

We recommend health care professionals should consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.

— WPATH SOC8 Recommendation 9.2

The fantasy world of the activist has made it into print. 

Transsexualism, as it used to be called, was regarded as a psychiatric disorder in adults that may require treatment — psychotherapy, psychiatry and in extremis, hormone therapy and surgery. At the same time, under watchful waiting, children were allowed to grow up and probably grow out of it.

That was sound and sensible. This offering by WPATH is nothing of the sort. The disorder to be treated has become a lifestyle to be affirmed, and without question. But it should not be one which is treated with drugs and surgery without question, not for adults and certainly not for children and adolescents.

Crucially, these so-called Standards of Care must not be adopted without lots of questions, from the NHS, the Royal Colleges and concerned members of the public. The activists might have taken over the institution; they must not be allowed to dictate the standards of care for vulnerable people.

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