What’s wrong with WPATH version 8?

Guest post by James Esses, of Thoughtful Therapists

On 6th September 2022, the World Professional Association for Transgender Health (WPATH) published its updated Standards of Care: Version 8.

WPATH was founded in 1979 as a self-regulated membership body. Its stated purpose is to “promote evidence-based care, education, research, advocacy, public policy, and respect in transgender health”. There have long been concerns that the organisation acts more as a partisan lobby group underpinned by gender ideology, instead of a body driven by medical evidence. Many of the senior members of WPATH identify as “trans” or “non-binary” themselves or are gender activists. Susie Green, the CEO of the organisation Mermaids, sits on the body responsible for revisions to the Standards of Care.

The Standards of Care are not official standards, but are influential around the world. WPATH calls them “internationally accepted guidelines”. The NHS refers to the WPATH Standards of Care in a variety of medical documents (including the previous service specification for the Tavistock Gender and Identity Development Service clinic). The Scottish government also relies on them in its decision-making. The Standards of Care featured heavily in the significant case of Bell v Tavistock. These guidelines have been used by numerous private health clinics throughout the UK, to justify irreversible treatment on children and young people.

What is new and worse in version 8

The latest version of the WPATH Standards of Care is extremely concerning in terms of medical evidence, ethics and child safeguarding. The most concerning aspects are:

1. Ideologically driven language – The guidelines feature language based in ideology, rather than medicine or biology, throughout. For example, irreversible medical and surgical interventions are referred to as “gender-affirming health care”. Double mastectomies are called “chest masculinization surgery”. Ideological terms such as “cisgender” are used, as well as the scientifically and factually inaccurate term “sex assigned at birth”.

2. Removal of minimum ages for irreversible medicalisation – The standard does not place any weight on nuanced concern for the welfare and wellbeing of vulnerable children. It does not consider that gender dysphoria is a mental-health symptom and many young people have co-morbidities such as autism and mental-health diagnoses. The guidelines have removed any minimum age limit for a child to be given puberty blockers, cross-sex hormones or sex-reassignment surgery (so long as that child has reached ‘Tanner Stage 2’ of puberty, which can be as young as nine years old). Interestingly, minimum ages had been included in the originally published document before these were quickly removed via a ‘correction’ online. The guidelines state that double mastectomies, euphemistically called ‘chest masculinization surgery’, “can be considered in minors”. Equally, ‘vaginoplasty’ may be considered for under 18-year-olds. The guidelines make it clear that there should be no requirement for a child to have taken cross-sex hormones prior to surgery, “if not desired” by a child – emphasising the consumeristic nature of these guidelines. Hormone treatment is recommended even though it can cause infertility

3. Chest binding and genital tucking for children – Healthcare professionals are instructed to provide education to children on both ‘chest binding’ and ‘genital tucking’, on the basis that this will provide “comfort” and “lower rates of misgendering”. Chest binding can cause pain, infection and even fractures and the tucking can cause decreased sperm concentration.

4. Alienation of parents – Healthcare professionals are advised to “challenge” parents who are unsupportive of their child medically transitioning. Equally, they are recommended to prescribe hormone treatment for children without parental involvement, if such involvement would be “harmful or unnecessary”.

5. Focus on irreversible surgery – The guidelines provides a ‘shopping list’ of recommended surgery for children and adults with ‘trans’ identities. These include, but are not limited to:

6. Abandonment of mental-health safeguarding – 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.

7. Disregarding of mental ill-health – Clinicians are advised that not all mental illness “can or should be resolved” prior to prescribing irreversible medication or surgery. The standard recommends that hormone treatment should not be withheld simply because a child has a ‘neurodevelopment condition’.

8. Eunuchs – A completely new chapter is dedicated to ‘Eunuchs’ who are defined as individuals who are “assigned male at birth and wish to eliminate masculine physical features or genitals”. The guidelines appear to support individuals who seek “castration” and they are now deemed to fall under the “gender diverse umbrella”. From an ethical and therapeutic standpoint, this is deeply concerning.

9. Patients in prisons and psychiatric hospitals – WPATH recommends that staff providing care to individuals resident in prisons or psychiatric hospitals should support them with “gender-affirming surgical treatment… when sought by the individual without undue delay”. This instruction for an unconditionally affirmative approach appears to throw any semblance of safeguarding or medical caution out of the window.

10. Ignoring the lack of studies – All of the above is recommend, notwithstanding the fact that WPATH acknowledges that “the number of studies is still low”, that “there are few outcome studies that follow youth in adulthood” and that “no clinical studies have reported on profiles of adolescents who regret their initial decision”.

WPATH diverges from the evidence

The recommendations of the WPATH Standard of Care are in stark contrast to the recommendations made by Dr Hilary Cass in her interim report on the treatment of gender-questioning children by the NHS. She states that:

“Any child or young person being considered for hormone treatment should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing.”

The UK’s National Institute for Clinical Evidence (NICE) has undertaken systematic evidence reviews on the use of puberty blockers and feminising/masculinising hormones in children and young people with gender dysphoria. The available evidence was not deemed strong enough to form the basis of a policy position. The Cass Review is continuing to develop qualitative and quantitative research to uncover patterns and quantify problems, to address the shortcomings in evidence.

Professor Michael Biggs’* new paper on the history of paediatric gender medicine scrutinises the evidence to support treating children with puberty blockers and cross-sex hormones. He finds that “the intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible”. 

The WPATH Standard undermines the safeguarding of some of society’s most vulnerable children and young people.The UK National Health Service and medical professions should not adopt the new WPATH Standard as a guide to the medical and therapeutic treatment for gender dysphoria, or in commissioning the replacement service for GIDS. The Cass Review is considering evidence in relation to hormone treatment for children. NICE should also undertake an evidence review of surgical and hormonal treatment for adults.

* Michael Biggs is a member of Sex Matters’ board.