WPATH evidence on trial

In the past three years, the US federal government has been strongly in favour of so-called “gender-affirmative” treatment, while over 20 US states have taken the opposite view, enacting laws banning puberty blockers, cross-sex hormones and surgery for gender-distressed children. 

In July 2023, the Sixth Circuit Court of Appeals rejected an appeal brought by some families and gender medicine providers to block the Tennessee law banning puberty blockers, hormones and surgery for minors.

The Supreme Court is due to hear a challenge to that decision from the federal government, on the ground that it violates the Equal Protection Clause of the Fourteenth Amendment of the US Constitution. The federal government argues that because, for example, puberty blockers or hormones may be given to a child with delayed or precocious puberty, it is sex discrimination not to allow a child to be given the same drugs or surgery in order to appear more like the opposite sex. Its argument relies on the World Professional Association of Transgender Health (WPATH) as providing “evidence-based guidelines… reflecting the accepted standard of care for treating gender dysphoria”.

The eighth version of the WPATH standards of care (SOC8) was developed by a committee of supporters and practitioners of gender-affirmative care. The committee was chaired by sexologist Dr Eli Coleman and led by two WPATH presidents: Dr Walter Bouman, a clinician at the NHS Nottingham Centre for Transgender Healthcare, and Dr Marci Bowers, a transgender surgeon. 

SOC8 describes not just puberty blockers and cross-sex hormones, but major surgeries such as castration, vaginoplasty, hysterectomy and breast removal, as “medical necessity”, including for children. It does not recommend any minimum ages for any hormonal or surgical interventions other than phalloplasty – the construction of a neo-phallus using skin, muscle, nerves and blood vessels harvested from a patient’s arm or thigh. All other surgeries and interventions are presented as “medically necessary gender-affirming medical treatment in adolescents”.

In separate litigation in defence of a similar law,  the state of Alabama has investigated WPATH’s guidelines, received documents and taken oral depositions. It says that what it has found is a “medical, legal, and political scandal that will be studied for decades to come”. It lays this out in an amicus brief (a written argument provided by a non-party to litigation in order to assist the court) to the Tennessee case. The amicus brief argues that:

“Though WPATH cloaks itself in the garb of evidence-based medicine, its heart is in advocacy.”

WPATH and others have put in their own amicus brief making the familiar argument – comprehensively rebutted by the Cass Review of child gender medicine earlier this year – that parents must choose between a dead child or a trans child. 

“If not treated, or treated improperly, gender dysphoria can result in debilitating anxiety, depression, and self-harm, and is associated with suicidality. As such, the effective treatment of gender dysphoria saves lives.” 

The amicus brief submitted by the Attorney General of the State of Alabama confirms issues previously exposed by Genevieve Gluck at Reduxx and by Mia Hughes and Michael Shellenberger in the leaked messages from internal WPATH chatboards known as the “WPATH files”. 

Yet in the UK, the NHS in Nottinghamshire is currently advertising for clinical psychologists to work with children, with the job ad stating as among the essential criteria for applicants:

“Understanding of the underlying principles of management and treatment in transgender healthcare, including their international frameworks (WPATH SOC 8).”

Below is a summary of the five most explosive claims about WPATH SOC8 made in the 50-page amicus brief from the state of Alabama.

1. WPATH’s standards of care are not evidence-based 

The WPATH standards are based on a structured process of building expert consensus. WPATH says that its methodology managed conflicts of interest; used the “GRADE framework” for systematic evidence reviews to tailor recommendation statements based on the strength of evidence; and drew on systematic literature reviews conducted by an independent team from Johns Hopkins University. The state of Alabama says its “discovery revealed a different story” (pp 28–34).

In August 2020, the head of the Johns Hopkins team commissioned by WPATH wrote to officials at the US Department of Health and Human Services about its research into “multiple types of interventions (surgical, hormone, voice therapy…)”. She reported: “We found little to no evidence about children and adolescents.” The Johns Hopkins review team also told officials that WPATH was “trying to restrict [its] ability to publish” the findings. There was no systematic review on the chapter about the care of adolescents.

Exhibits put into evidence show that some SOC8 authors opted to conduct no systematic evidence reviews precisely because doing so would make the lack of evidence more obvious. One chapter lead wrote: 

“Our concerns, echoed by the social justice lawyers we spoke with, is that evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits.” 

Records disclosed in the discovery process for the Alabama litigation revealed authors discussing the concerning lack of evidence, and seeking to downplay it in the guidance. One wrote they were concerned that using language such as insufficient evidence and limited data would “empower” people who were concerned “that research in this field is low quality (ie small series, retrospective, no controls, etc…)”.

One of the lead authors, Dr Marci Bowers, apologised in a private email to other WPATH leaders for going public with concerns about puberty blockers, and wrote:

“Like my [female genital mutilation] patients who had never experienced orgasm, the puberty blockaded kids did not know what orgasm might feel like and most experienced sensation to their genitalia no differently than if it had been a finger or a portion of their thigh… My concern culminated during a presurgical evaluation on a young trans girl from a highly educated family whose daughter responded when I asked about orgasm, “what is that?” The parents countered with, “oh honey, didn’t they teach you that in school?” I felt that our informed consent process might not be enough…. It occurred to me that how could anyone truly know how important sexual function was to a relationship, to happiness? It isn’t an easy question to answer.”

(For clarity, a “trans girl” is a boy who identifies as a girl. The child in question, though referred to as a daughter, is male.)

2. Authors have conflicts of interest

WPATH cited, but largely ignored, international standards on conflicts of interest. These standards recognise that people who make a living out of providing a service should not play a central role in creating guidance for how that service is provided (pp 24–28). Clinicians who provide the services at issue should be represented but should be no more than a minority of the guideline development group. Yet SOC8’s authorship was limited to existing WPATH members – clinicians and others who were enthusiastic about medical and surgical transition treatments. Discovery showed that Dr Bowers said it was “important for someone to be an advocate for [transitioning] treatments before the guidelines were created”.

WPATH assured readers that “no conflicts of interest were deemed significant or consequential” in crafting SOC8. But Dr Coleman admitted at his deposition in the Alabama litigation that “most participants in the SOC8 process had financial and/or non-financial conflicts of interest”. Bowers has undertaken more than 2,000 vaginoplasties and made “more than a million dollars” last year from providing transition surgeries, but said it would be “absurd” to consider that a conflict worth disclosing or otherwise accounting for as part of SOC8. Dr Coleman testified that he did not know of any author removed from SOC8 due to a conflict.

Many authors frequently served as expert witnesses to advocate for sex-change procedures in court; Dr Coleman testified that he thought it was “ethically justifiable” for those authors to “advocate for language changes [in SOC8] to strengthen [their] position in court”. One contributor to SOC8 wrote: 

“My hope with these SoC is that they land in such a way as to have serious effect in the law and policy settings that have affected us so much recently; even if the wording isn’t quite correct for people who have the background you and I have.” 

Another said: 

“The wording of our section for Version 7 has been critical to our successes [in court] and I hope the same will hold for Version 8.” 

Another said: 

“We need a tool for our attorneys to use in defending access to care.”

3. Weak recommendations became strong recommendations

WPATH said that it used a process “adapted from the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework” for “developing and presenting summaries of evidence” using a “systematic approach for making clinical practice recommendations”. But the chair of the mental-health chapter testified that rather than relying on systematic reviews, some drafters simply “used authors… we were familiar with”.

The amicus brief also highlights that WPATH appears to have ordered the removal of annotations disclosing the quality of evidence underpinning the recommendations. Early drafts had recommendations graded into strong and weak, with the quality of evidence provided as ++++ (strong certainty of evidence), +++ (moderate certainty of evidence), ++ (low certainty of evidence) or + (very low certainty of evidence). An email to an author at the review stage said: “My understanding was that we were not going to make a difference between statements based on [literature reviews] and the rest, is that right If so, we will need to remove the +, ++, +++.” The ratings were removed and recommendations themselves appeared to morph from weak (“we suggest”) to strong (“we recommend”) (pp 28–32).

4. Age limits were removed

Admiral Rachel Levine, the US Assistant Secretary for Health, was in frequent contact with WPATH leaders. (Evidence indicates that Levine met or communicated with WPATH leaders about SOC8 on 12th August, 26th August and 22nd November 2021; and 2nd May, 31st May, 10th June, 1st July – this meeting may have involved only Levine’s chief of staff, 26th July, 5th August, 8th August and 3rd September 2022). According to one WPATH member who met with Levine: “The failure of WPATH to be ready with SOC8 [was] proving to be a barrier to optimal policy progress.” (pp 15–20)

A few months before SOC8 was to be published in September 2022, WPATH sent Admiral Levine a draft marked “Embargoed Copy – For Your Eyes Only”. The draft already included a departure from the previous Standards of Care which, except for so-called “top surgeries” (bilateral mastectomies), restricted surgeries to patients who had reached the “age of majority in a given country” (this recommendation was often ignored in practice).

The draft of SOC8 relaxed the recommended minimum ages to 14 for cross-sex hormones, 15 for “chest masculinisation” (double mastectomy), 16 for “breast augmentation, facial surgery (including rhinoplasty [nose reshaping], tracheal shave [surgical reduction of the Adam’s apple], and genioplasty [chin reshaping])”, 17 for “metoidioplasty [surgery to make a clitoris that has been enlarged by taking testosterone look more like a mini-phallus], orchiectomy [removal of the testicles], vaginoplasty [construction of a neovagina out of the skin of the penis], hysterectomy [removal of the uterus] and fronto-orbital remodeling [surgery to reshape the skull]”, and 18 for phalloplasty. Each recommendation had a qualifier that could allow for surgery at an earlier age on a case-by-case basis. 

Admiral Levine’s office wrote in an email that the listing of “specific minimum ages for treatment… will result in devastating legislation for trans care”. Levine’s chief of staff suggested that WPATH remove the age limits from SOC8 and create an “adjunct document” that could be “published or distributed in a way that is less visible”.

WPATH initially told Levine that it “could not remove [the age minimums] from the document” because the recommendations had already been approved by SOC8’s consensus process. It added that “we heard your comments regarding the minimal age criteria” and “consequently, we have made changes to the SOC8” by downgrading the age “recommendation” to a “suggestion”. Levine sought more meetings with WPATH; after Levine’s intervention, and days before SOC8 was due to be published, WPATH came under pressure from the American Academy of Pediatrics, which threatened to oppose SOC8 if the age criteria remained. [pp19-20] They were removed. 

A footnote in the amicus brief says: “SOC-8 was initially published with the age minimums intact, so WPATH had to quickly issue a ‘correction’ to remove them. Remarkably, WPATH then had the correction itself removed.”

Dr Coleman said in his deposition that WPATH removed the age minimums “without being presented any new science of which the committee was previously unaware”. Papers show that the last-minute decision was to be treated as “highly, highly confidential”. Rather than explaining what had actually happened, WPATH leaders promptly sought for “all [to] get on the same exact page, and PRONTO”. Dr Bowers encouraged contributors to submit to “centralized authority” so there would not be “differences that can be exposed” and explained that the public messaging “is a balancing act between what I feel to be true and what we need to say”.

5. Castration of “eunuchs” was recommended

SOC8 includes a chapter on “eunuchs” – “individuals assigned male at birth” who “wish to eliminate masculine physical features, masculine genitals, or genital functioning”. Because eunuchs “wish for a body that is compatible with their eunuch identity”, WPATH recommends the castration of men and boys who identify as eunuchs (pp 34–36). 

This chapter relies on evidence from the Eunuch Archive, a “large online peer support community”. According to SOC8, it contains “the greatest wealth of information about contemporary eunuch-identified people”. Alabama’s amicus brief notes that SOC8 does not disclose that part of this “wealth” comes in the form of the archive’s fiction repository, made up of thousands of stories that “focus on the eroticization of child castration” and “involve the sadistic sexual abuse of children”, including themes such as “Nazi doctors castrating children, baby boys being fed milk with estrogen in order to be violently sex trafficked as adolescents, and pedophilic fantasies of children who have been castrated to halt their puberty”.

Dr Coleman confirmed in his deposition that if a physically healthy male who has no recognised mental-health conditions and is not at high risk of self-castration identifies as a eunuch, the WPATH standards support his castration.