New guidelines for transgender medicine are undermined by a weak evidence base
GCN asked various people for their thoughts on the World Professional Association for Transgender Health’s new standards of care, SOC 8, focusing on children and adolescents. The resulting commentary, in alphabetical order by surname, has been divided into two parts. This is the second part. (The first part is here.)
Riitakerttu Kaltiala, professor of adolescent psychiatry, clinician and researcher in Finland (which in 2020 broke with the WPATH approach and shifted to psychotherapy as the first-line treatment for gender-dysphoric youth):
I have to admit that the [new WPATH] standard is better than I expected, because there is an emphasis that any interventions with adolescents have to be based on a thorough assessment. And this guideline even admits that it may not always be the right course to proceed quickly to hormonal — not to mention surgical — interventions in adolescents. It is embedded in this guideline that some adolescents may thrive without any medical intervention.
But on the other hand, I think the Dutch model [of puberty blockers, followed by cross-sex hormones and surgery] is still presented in too positive a light [in SOC 8], because actually the Dutch model of care is based on one very small study with carefully selected patients. And the comparison group that they used in this study was not comparable to the intervention [or treatment] group. Even if it were [comparable], the comparison group was doing worse to start with. And the intervention group [had] optimal patients — they were doing well psychologically, had appropriately supportive parents, and were functioning very well cognitively. It is to be expected that they would be doing better in the end than the comparison group, who were not eligible [for treatment] because of mental disorders or chaotic life situations, substance-use disorders or hesitations about the identity.
I think this study [which led to international adoption of the Dutch medical model] does not have such power of evidence as it is presented. Nobody has been able to really repeat it, it has not been replicated. So the evidence base for the Dutch model is very weak, and this is not [sufficiently] acknowledged in the [new WPATH] standards of care.
I would be hesitating [before any early, irreversible interventions]. In our clinic, the outcomes of treatment have not been that positive. First we published the finding that patients actually present with much more severe psychiatric disorders than the Dutch were talking about. Secondly, most of the patients nowadays have adolescent-onset of gender dysphoria, and the Dutch model is not for that [patient group] at all. The Dutch model was tailored for those who had clear childhood-onset gender dysphoria that intensified in puberty. It should be emphasised more clearly that the Dutch model — the little evidence we have for the Dutch model — is only for a subgroup of the patients.
And then our own experiences [in Finnish research and clinically] and in research have been more pessimistic about the outcomes. These findings, these observations, do not justify lowering the age limits for irreversible interventions.
We do not know about the safety [of the Dutch model], particularly in relation to cognitive development and brain development in general. We know nothing about the natural course of adolescent-onset gender dysphoria. We don't know about safety and outcomes from treatment of adolescent-onset dysphoria with hormonal, not to mention surgical, interventions. And therefore, I think, in addition to thorough assessment, maybe more caution should be advised with interventions initiated during developmental years [of adolescence].
There's so much we don't yet know, that we should be really cautious and vigorously obtain new research knowledge, evidence for what would be the best course of action [with today’s dysphoric youth]. And therefore, I don't think it is appropriate to give way to initiating [medical treatment] more quickly and more easily with younger people.
But [WPATH] give way in this guideline for surgeries under-age in certain situations, and they give way to initiating cross-sex hormones earlier, and [there is] also the non-critical approach to affirmative care with children — these are problematic points.
SOC 8: A compelling reason for earlier initiation of [cross-sex hormones], for example, might be to avoid prolonged pubertal suppression, given potential bone health concerns and the psychosocial implications of delaying puberty …
Aaron Kimberly, mental health clinician and founder of Gender Dysphoria Alliance:
WPATH doesn’t define gender dysphoria/incongruence, and there are no clear inclusion/exclusion criteria. Not defining what gender dysphoria is — nor educating patients & families about what gender dysphoria is — undermines the comprehensive assessment recommended in the adolescent charter of SOC 8.
What are we assessing for, exactly, unless we understand what gender dysphoria is? How are autism symptoms or body dysmorphia different from gender dysphoria? How will a physician make an accurate differential diagnosis?
What is a patient with gender dysphoria consenting to [if they don’t] understand the nature of their experience?
I understand [WPATH] wants to destigmatise the pathways to gender dysphoria — which is good — but destigmatising any other human phenomenon has meant educating the patient/public, not hiding the realities of those phenomena.
What [WPATH is] doing not only undermines sound clinical practice, but undermines my own experience of gender dysphoria. It undermines my ability to communicate my experience in ways that make sense to people and destigmatise it.
The SOC doesn’t provide clinicians with any evidence-based insights into what causes that perception of gender incongruence, even though three distinct pathways have been well researched and outlined in the [psychiatric diagnosis manual] DSM-5.
Those three pathways are —
early onset (highly correlated with homosexuality, especially in males)
late onset (related to transvestic disorder with autogynephilia, which intensifies in adolescence or adulthood and progresses into gender dysphoria)
related to differences of sexual development (presents in early childhood)
People may make different choices, depending on the information they receive. People with different experiences also have different needs.
WPATH has clearly been influenced by activism which seeks to obscure the realities of gender dysphoria, and include an ever-expanding list of other conditions and experiences, such as castration fetishes, under the banner of “trans”.
With other versions of the SOC, there have been wildly differing interpretations and practices from clinic to clinic, with very little oversight. There is nothing binding clinicians to following the SOC, and the SOC is so broad and vague that anyone can say they’re following it — but according to their own biases and interpretation.
SOC 8: We recommend health care professionals working with gender diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children.
SOC 8: Due to the lack of research into the treatment of children who may identify as eunuchs, we refrain from making specific suggestions.
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Lisa MacRichards (a pseudonym), works at a Canadian hospital and holds a Master of Science degree, author of a 2019 critical analysis of WPATH’s SOC 7:
I look forward to seeing if guideline databases will now see the SOC 8 as meeting criteria to be included in their databases [such as the ECRI Guidelines Trust database] and be graded [for the quality of the evidence supporting SOC 8 recommendations].
The same conflicts of interest mentioned in my article [for example, WPATH committee members who receive income based on guideline recommendations] still apply to the SOC 8. They are supposed to defend their treatment paradigm, and they didn’t.
SOC 8: While evidence-based research provides the basis for sound clinical practice guidelines and recommendations, it must be balanced by the realities and feasibility of providing care in diverse settings.
Philip Morris, psychiatrist and president of Australia’s National Association of Practising Psychiatrists, lead author of a health practitioners’ guide to managing gender dysphoric youth:
The new edition of the WPATH guidelines includes more cautious recommendations about use of medically affirming treatments in adolescents, acknowledges the potential adverse effects on cognitive development of prolonged puberty blockade, and the benefit of psychotherapy for children that addresses gender exploration, rather than gender affirmation.
SOC 8: Given the lifelong implications of medical treatment and the young age at which treatments may be started, adolescents, their parents, and care providers should be informed about the nature of the evidence base. It seems reasonable that decisions to move forward with medical and surgical treatments should be made carefully.
SOC 8: Puberty is a time of significant brain and cognitive development. The potential neurodevelopmental impact of extended pubertal suppression in gender diverse youth has been specifically identified as an area in need of continued study (Chen et al., 2020).
It is good to see that WPATH has become more aware that there is a growing issue among young people seeking permanent medical pathways before their bodies have finished development, yet there is no mention of either child safeguarding or child protection within the SOC 8 document. This seems to me an astonishing omission.
It was completely inappropriate of WPATH to remove minimum age requirements for major surgeries, cross-sex hormones and all other medical interventions. Children and teenagers need clinicians to understand how stages of development have a significant impact. To disregard these issues is going to cause a good deal of harm to vulnerable young people.
There appear to be 119 signatories on this SOC, how on earth did all 119 manage to sign off on the correction which came out some hours later? This is not a correction, this is an ideological turnaround.
I believe that WPATH will come to regret the decision to include a chapter on eunuchs. They will also regret deciding not to include a chapter on detransition and regret. WPATH suggests that detransition is due to lack of acceptance. This is an incorrect interpretation of the detransition process.
Although there is some mention of both Vandenbusche and Littman's studies, yet not enough attention was shown to Littman's critically important peer-reviewed study of 100 detransitioners. The information evident in this study is very significant and should not have been omitted in a document that purports to provide a comprehensive overview of the treatment of gender dysphoria.
The regret statistic of 4 per cent seems to be pure fantasy [WPATH states a regret rate of 0.3-3.8 per cent post-surgery]. As far as I can see this 4 per cent is taken only from patients who returned to the clinic seeking further support. Considering the fact that Lisa Littman’s study showed that 76 per cent of detransitioners did not inform the clinic that they had detransitioned, to focus only on patients who contact the clinic is either disingenuous or else purposefully seeking to diminish the worrying trend of trans people regretting their medical transition and seeking to detransition.
This document does not meet the criteria for a standard of care — it identifies as a standard of care and any clinician who follows these inappropriate guidelines will be vulnerable to future lawsuits.
WPATH have discredited themselves with this document. I hope that the inevitable fallout that will occur as professionals across the world realise the shoddy nature of the work involved in this document will induce some caution in the American Academy of Pediatrics and the Endocrine Society.
SOC 8: … providers should be prepared to support adolescents who detransition. In an internet convenience sample survey of 237 self-identified detransitioners with a mean age of 25.02 years, which consisted of over 90 per cent of birth assigned females, 25 per cent had medically transitioned before age 18 and 14 per cent detransitioned before age 18 (Vandenbussche, 2021). Although an internet convenience sample is subject to selection of respondents, this study suggests detransitioning may occur in young transgender adolescents and health care professionals should be aware of this. Many of them expressed difficulties finding help during their detransition process and reported their detransition was an isolating experience during which they did not receive either sufficient or appropriate support (Vandenbussche, 2021).
Patrick Parkinson, Australian professor of law:
There are increasing legal vulnerabilities for these clinicians. WPATH now says clearly that parents and adolescents need to be told about the limits of the evidence base, which is constantly developing. If the clinician gives too optimistic an assessment of this, or conversely too pessimistic a view of suicidal ideation and attempts, she or he may be liable because the consent of the patient is not properly and fully informed. Parents will need to be told plainly that there is no way of telling if a child will continue to be trans-identified in the long term and that some will regret the treatment when they are grown up.
SOC 8: A necessary step in the informed consent/ assent process for considering gender-affirming medical care is a careful discussion with qualified [health professionals] trained to assess the emotional and cognitive maturity of adolescents. The reversible and irreversible effects of the treatment, as well as fertility preservation options (when applicable), and all potential risks and benefits of the intervention are important components of the discussion. These discussions are required when obtaining informed consent/assent. Assessment of cognitive and emotional maturity is important because it helps the care team understand the adolescent’s capacity to be informed.
The fact that a separate chapter regarding adolescents was created for the first time in the SOC8 suggests a recognition that something has changed. This presentation, of adolescent-onset gender dysphoria, and the corresponding increase in gender referrals, have been interpreted [by WPATH] as the emergence of a lesser-understood subtype of gender dysphoria, that would nevertheless benefit from transition.
The SOC acknowledges, in this age group, a high correlation with autism and other co-morbid mental health issues presenting alongside gender dysphoria. It also mentions desistance, detransition, and Lisa Littman’s research on rapid-onset gender dysphoria. But instead of acknowledging these phenomena as serious subjects of concern that should lead to a rethinking of transition in this population, for the most part, they are interpreted from a perspective that suggests the benefits of transition can outweigh potential risks.
In the event that parental resistance is encountered, “the engagement of larger systems of advocacy and support” is suggested. In my opinion, the entire system appears to be championing one outcome for these children, regardless of whether it is the right one.
The removal of minimum age requirements is concerning, to say the least. Does anyone actually believe a child can consent to interventions that will potentially affect their bodies and fertility permanently?
I have come across cases in which surgery was allowed at ages younger than those recommended by the previous guidelines [SOC 7], so it’s possible that children will now be granted access to these interventions at younger ages than ever before.
Of note, social transition is suggested [by SOC 8] despite being associated with persistence of gender dysphoria.
I believe that many people who are in favour of this approach believe that they are doing the right thing by being patient-led and loosening restrictions around access to transition. That said, clinical care should always be informed by the scientific literature, even if it runs contrary to what patients or activist groups want. Any treatment approach that fails to do this, or that dismisses or downplays particular findings because the issue is political, will not lead to good outcomes for its patients.
The U.K. and Europe are rightly moving in a different direction with regard to treating children with gender dysphoria, showing greater caution and scepticism. But in North America, we are continuing to steamroll in the opposite direction. I think the new SOC is reflective of this.
I think it is going to be a while before so-called “gender-affirming care” for minors reverses its course; if anything, those in favour of it are likely doubling down now.
SOC 8: 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. Gender social transition refers to a process by which a child is acknowledged by others and has the opportunity to live publicly, either in all situations or in certain situations, in the gender identity they affirm and has no singular set of parameters or actions (Ehrensaft et al., 2018).
Writing from elsewhere, a selection of other commentary on SOC 8
Although detransition is still assumed by [WPATH] to be rare, they write that “Some adolescents may regret the steps they have taken.” Sometimes a “young person will want to stop treatment and return to living in the birth-assigned gender role in the future.” [Author’s emphasis.] Maybe that should even be discussed with kids before they transition, they surmise, and also, “providers should be prepared to support adolescents who detransition”. Here they are acknowledging rapid-onset gender dysphoria, albeit without naming it, and the increasing phenomenon of detransition — journalist Lisa Selin Davis
WPATH’s 27th Scientific Symposium, which was held between September 16-20 in Montreal, was the site of a number of extraordinary developments whose impact will be felt for a long time. Among them was a presentation by Thomas W. Johnson, a professor emeritus of anthropology at California State University, discussing a chapter in the new Standards of Care issued by the organisation which designates “those who identify as eunuchs” suffering from “Male-to-Eunuch Gender Dysphoria” as subjects with a need for “gender-affirming care” as a part of the “gender diverse umbrella” — Wesley Yang of Year Zero
… the decision by an authoritative body like WPATH to treat wannabe eunuchs as having unfairly stigmatised sexual identity, just like any other sheltering under the LGBTQI+ rainbow, has a number of undesirable effects. Most obviously, WPATH’s overtly sympathetic presentation of castration will surely increase the likelihood of larger numbers of males eventually self-mutilating. And apart from making a mockery of genuinely threatened sexual identities, the attempted assimilation of fetishism into LGBT rights makes a popular backlash against the whole of lot of us more likely too. In the old days, the activist’s aim was to demonstrate that gay people are not sexual deviants. These days, activists seem to want to suggest that sexual deviants are just like the gays — philosopher Kathleen Stock