Who should develop guidelines on transgender healthcare?
The World Health Organisation (WHO) is developing new guidelines for transgender health. It announced the proposed members of the group to do this on 18th December 2023 (see the Daily Mail report to find out who’s who).
The planned guidelines are set to cover:
WHO announcement, December 2023
- provision of gender-affirming care, including hormones
- health workers education and training for the provision of gender-inclusive care
- provision of health care for trans and gender diverse people who suffered interpersonal violence based in their needs
- health policies that support gender-inclusive care
- legal recognition of self-determined gender identity.
Following complaints about the short deadline it was extended to 2nd February 2024.
Several groups have submitted detailed comments including Sex Matters, Clinical Advisory Network on Sex and Gender (CAN-SG), Fair Play For Women, Genspect, LGB Alliance, the Society for Evidence Based Gender Medicine (SEGM), Transgender Trend, Thoughtful Therapists and With Woman, as well as the UN Special Rapporteur on violence against women and girls.
Highlights from the submissions
Sex Matters
Sex Matters wrote from a human-rights perspective, and said that in trying to appease trans-rights activists WHO risks undermining its own governance, purpose and culture:
- The mandate and make-up of the group do not reflect WHO’s principles of human rights, universality and equity, or its commitment to be guided by the best available science and evidence.
- If WHO is considering the efficacy and ethics of medical intervention to support the desire of people to live as the opposite sex, it must recognise that there are conflicts with the rights of other people, including their freedom of belief and expression.
- None of the proposed panel members has experience in considering other people’s human rights in relation to transition, and many in fact have a track record of disregarding them.
CAN-SG
The Clinical Advisory Network on Sex and Gender is a network of clinicians from the healthcare professions mainly in the UK and Ireland. They argue that the WHO’s approach is out of touch with the latest medical evidence and understanding.
- WHO’s apparent assumption is that “gender-affirming care” is safe and effective: this is incorrect and has therefore been abandoned by Finland, Sweden and England explicitly in children and adolescents.
- WHO’s framing of self-determined gender identity as a human right for trans people ignores its harmful public-health consequences when people claim access to the rights of the opposite sex, and its undermining of accurate data collection, and therefore efforts to tackle inequality.
- The guideline development group represent groups on only one side of the debate. Five of the eight clinicians on the panel have held prominent positions in the World Professional Association for Transgender Health (WPATH).
Fair Play For Women
Fair Play For Women, a campaigning and consultancy organisation which raises awareness, provides evidence and analysis and works to protect the sex-based rights of women and girls in the UK, asked the group to reconsider its mandate, its focus and its make-up.
- The group has a bias towards an interventionist approach, which is one increasingly being called into question by experts.
- The proposed focus of the guideline has a bias in outcomes built into its specification: but gender affirmation and medical intervention for gender issues are highly contested, particularly for children.
- The proposed focus includes legal recognition of self-determined gender identity, which is not a healthcare issue, nor a legitimate part of the mandate for this group or one it is qualified to address.
- The timeline for the group is insufficient for a rigorous review that will generate a robust and reliable set of guidelines.
Read Fair Play For Women’s submission.
Genspect
Genspect, an international interdisciplinary professional and educational organisation devoted to advancing a healthy approach to sex and gender, listed grave concerns about WHO’s plans alongside comprehensive references.
The composition of the panel:
- includes at least 10 people who are trans, but not a single detransitioner to give the case against “gender-affirming care” despite significant numbers who feel they were harmed by it
- does not include any legal experts, nor anyone with expertise in professional mental health or in autism or neurodiversity.
The guideline focus and the panel both show bias:
- in favour of gender-affirming care, with no acknowledgement of significant professional disagreement worldwide or the complex clinical presentation of trans and gender-diverse individuals.
- in favour of legal recognition of self-determined gender identity, a complex and controversial issue that has proved problematic – particularly in Ireland, where Genspect is partly based – with no acknowledgement of its impact on the safety and dignity of women and girls.
Genspect urges the WHO to pause this process; revise the guidelines to recognise diverse viewpoints; make the group more diverse in views and experience; and make the process transparent and balanced.
LGB Alliance
LGB Alliance, a UK-based charity formed to advance lesbian, gay and bisexual rights, said that the WHO consultation “exemplifies the conflation of healthcare with politics”, breaches WHO’s own rules and risks causing harm to young people, particularly those who are lesbian, gay or bisexual.
- The announcement of this consultation breaches WHO’s own rules for guideline development – there is inbuilt bias both in the composition of the group and in the focus of the announcement.
- In promoting the idea that it is possible to change sex and supporting the use of experimental off-label medical treatment and radical surgery, WHO is promoting false and irresponsible messages to children and young people.
- Lesbians seem to be of little concern to WHO, especially in its lack of awareness of the growing number of young lesbians undergoing unnecessary and irreversible medical and surgical interventions.
UN Special Rapporteur on violence against women and girls, its causes and consequences
Reem Alsalem responded in her capacity as the UN Special Rapporteur on violence against women and girls, its causes and consequences, to raise serious concerns, saying that the February meeting should be postponed until these problems can be addressed.
- The composition of the development group has significant unmanaged conflicts of interest, and the majority of the members clearly have strong, one-sided views: not one appears to represent a voice of caution for medicalising youth with gender dysphoria or the protection of female-only spaces.
- The group seems to have been three-quarters formed before consultation began. It is clear that members were invited from several transgender advocacy organisations, but not from those with differing views, nor from patients harmed by access to hormones or parents of youth with post-pubertal onset of gender dysphoria.
- WHO’s response to widespread concerns implies that conflicts of interest in the panel should be reported by the public; WHO’s handbook says that responsibility rests with WHO.
- WHO is advocating for legal recognition of self-determined gender identity without considering its human rights-related impacts on wider affected groups, or the legitimate need for female-only spaces, and the right of all women and girls to a life in dignity, safety and security that is free from violence.
Read the Special Rapporteur’s submission.
SEGM
The Society for Evidence Based Gender Medicine suggested that flaws in the process posed a critical risk to the credibility of WHO guidelines, flagging:
- a biased guideline panel composition
- an inappropriately handled public comment period
- the rushed guideline development process overall.
Further issues were raised:
- The language of the announcement did not appear to be neutral, suggesting that ideological decisions had been made before the panel had even met.
- Members of the group have significant conflicts of interest in one, two, or all three of the areas highlighted by WHO in its own guidance for panel selection.
- Members have made statements that seem to be unsupported by evidence.
There is a high risk of bias in the group due to:
- strong pro-transition views held by the GDG members
- lack of any individuals or professionals concerned about the unfavourable harm-benefit profile of youth gender transition
- lack of independent methodological expertise.
Transgender Trend
Transgender Trend is a UK-based organisation, set up in 2015 to call for evidence-based healthcare for children with gender distress and for fact-based teaching about sex and gender in schools. Its response to WHO was brief but to the point, flagging:
- the unevidenced assumption that an affirmative, medicalised approach is the correct one, with no reference to any other options (which calls WHO’s motives for this exercise into question)
- the lack of independent professionals or anyone cautious about “gender-affirming care” on the panel, which mostly consists of trans activists with unmanaged conflicts of interest and goes against WHO’s own guidance
- a rushed and shoddy process that risks a guideline that is ideologically biased, based on shaky evidence and unfit for purpose – in contrast with the rigorous Cass Review in the UK
- a model of care that is attracting worldwide consternation and professional re-evaluation
- a risk of the guideline failing professional, public and political scrutiny, discrediting the guideline and causing reputational damage to WHO itself.
Read Transgender Trend’s submission.
Thoughtful Therapists
Thoughtful Therapists is dedicated to ensuring the use of ethical, exploratory therapy for all clients and especially those suffering from gender related distress.
Its response urged the steering group to read CAN-SG’s statement, and raised further points:
- The legal recognition of self-determined gender identity is a highly contested political area and does not fall within this remit stated in the WHO’s own handbook for guideline development: it should be removed from the scope.
- Analysing the technical skills of the panel revealed a lack of impartiality – all the panellists are pro-affirmation to varying degrees – and no evidence of any expertise in impartiality or experience of literature reviews or grading research studies.
- The panel does not include diverse perspectives: too many panellists are transgender or non-binary and many have been senior members of highly pro-affirmative organisations – will they recuse themselves if their papers form part of the evidence they are asked to interpret?
- There are a number of panellists from countries where LGBT+ rights are criminalised or subject to discrimination, who specialise in HIV/AIDS prevention rather than transgender healthcare.
Read Thoughtful Therapists’ submission.
With Woman
With Woman is a grassroots collective of female midwives, healthcare workers, allied professionals, academics, peer counsellors, advocates and volunteers in the field of maternal and child health.
This organisation described the panel’s lack of any expertise in maternity and child health as a major gap given the number of young girls identifying as trans and the life-long consequences for maternal and child health that “gender affirming care” will have on them. It noted concerns about:
- the taking of testosterone during pregnancy with no evidence-based guidance
- bilateral mastectomies on girls as young as 13 with no discussion of how this will preclude future breastfeeding (with poorer outcomes for both mother and infant)
- the high risks and unpredictable results of phalloplasty
- the removal of the uterus or ovaries presented as healthcare
and the impact of any of these on future pregnancy and motherhood.
Read the whole letter from With Woman.
Petition signed by 11,846
A petition organised by the LGBT Courage Coalition (LGBTCC), a US organisation that opposes the censorship of critical voices in the issue of pediatric gender medicine, has been signed by nearly 12,000 people strongly objecting to the bias of the panel and the WHO’s stated plan to promote hormones and self-identified gender, and asking it to cancel the group’s first planned meeting and go back to the drawing board.