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WITH an estimated 2–3% of young people identifying as transgender or gender diverse (TGD), most health care professionals will provide care for a TGD person at some point.
Unfortunately, many TGD people have not experienced a high standard of care, whether it’s due to ignorance, insufficient knowledge and training, or even discrimination.
To help combat that, the World Professional Association for Transgender Health’s (WPATH) recently released its 8th Standards of Care edition (SOC-8).
“The overall goal … is to provide clinical guidance to health care professionals to assist transgender and gender diverse (TGD) people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfilment,” the authors wrote in the introduction.
The previous SOC-7 edition was published in 2012. One of the Australian authors of SOC-8, RMIT’s Professor Katherine Johnson, told InSight+ that the new edition is both an enhancement and advancement.
“There has been a new robust methodology based on Delphi method that ensures the principles are validated by a large panel of experts. There are new chapters and other chapters have been significantly undated and are based on the latest scientific research,” she said.
SOC-8 features 18 chapters including assessment of children and adolescents.
There was controversy when the original document included a list of minimum ages for treatments — 14 years for cross-sex hormones, 15 years for removal of breasts, 17 years for removal of testicles. However, these minimum ages were removed within hours of the document going online, with WPATH writing they were published “in error”.
In a WPATH webinar published on Twitter, lead author of the Child chapter, Dr Amy Tishelman, said instead of set ages, they wanted clinicians to be able to use their judgement.
“We wanted there to be some clinician judgment without being at risk for being held in court for not sticking completely to these standards,” she said.
Instead of age recommendations, WPATH suggests puberty blocks and cross-sex hormones can be administered when a child reaches Tanner stage 2, the first sign of puberty.
“The use of puberty-blocking medications, such as GnRH analogues, is not recommended until children have achieved a minimum of Tanner stage 2 of puberty because the experience of physical puberty may be critical for further gender identity development for some TGD adolescents,” the authors wrote.
This is not dissimilar to Australian standards. According to the 2018 Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents, adolescents can commence puberty-blocking medications when Tanner stage 2 has been achieved. They also need to have a diagnosis of “gender dysphoria in adolescence”, have received medical assessment including fertility preservation counselling, and have assent from the adolescent and informed consent from legal guardians.
Also included in the SOC-8 are chapters on assessment of adults, non-binary, primary care and institutional environments. New in this edition is a chapter on eunuchs, which is included “because of their unique presentation and their need for medically necessary gender-affirming care”.
According to Professor Johnson, these standards of care are more comprehensive in scope than the various Australian standards of care which have been endorsed by the Australian Professional Association for Transgender Health (AusPATH).
“But they share a similar ethos and expectation for how best practice health care should be delivered,” she explained.
Professor Johnson hopes SOC-8 can help improve the health care experience for TGD people.
“In Australia, the key issues are about ensuring knowledgeable health care experiences and timely access to appropriate and affordable health care.
“There is also a need for updating of professional knowledge about diversity within trans communities to ensure options for individualised, inclusive and personalised care for non-binary people that may or may not include medical intervention,” she explained.
“If a GP doesn’t have that knowledge, it is vital that they are open and accepting of the TGD person and offer to seek out appropriate support.
“Negative health care experiences can have a deeply detrimental impact on TGD people’s mental health and delay them from finding appropriate support,” she concluded.
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Thank you Dr Wilson for your articulate description of some of the concerns around WPATH guidelines and the lack of evidence base around these.
A class action clinical negligence lawsuit is currently in train in the UK alleging that children were inappropriately commenced onto puberty blockers without appropriate clinical assessment and without being given the opportunity to provide fully informed consent. Clinicians should in discussion with patients appropriately describe the low quality of evidence for long-term benefits of puberty blockers and the potential for lifelong harms including anorgasmia and sterility
The WPATH and AusPath guidelines are well-researched and evidence based, thank you for the update.
Disappointing to see close-minded and non-evidence based opinions (again) in the comments from medical practitioners, who can do better than following the arguments of people like JK Rowling and anti-transgender activists, who last I checked were not actively involved in research or treatment of transgender patients.
Assessment of transgender children and adolescents is done in a multidisciplinary clinic over a prolonged time period by multiple subspecialists, and most of the claims given by anti-trans “activists” are false. Would be ideal if people would actually read the guidelines themselves and speak to clinicians and trans people rather than making assumptions based on ideology.
This article fails to inform its readers around many of the controversies surrounding WPATH and its Standards of Care, leaving the impression that these Standards of Care are universally accepted. They are not.
WPATH promised that these new SoC would be evidence-based. This has not happened, because there is no good evidence behind puberty blockers and wrong sex hormones for children. These treatments have been independently assessed by NICE, the BMJ Evidence-Based Medicine journal, the Karolinska Institute and more recently Dr Hilary Cass among others. All found evidence to be poor. Dr Hilary Cass is a past President of the UK’s RCPCH, and was tasked by the UK government to independently review the treatment of gender questioning children. Her review should be mandatory reading, and indicates significant problems in this field. https://cass.independent-review.uk/publications/interim-report/
As a result of these reviews, many countries around the world are ceasing medical treatments for children and avoiding WPATH, a lobby group, and their recommendations. The list includes Sweden, Finland, France and the UK.
These SoC are concerning in many ways, not least the removal of any lower age limit for treatments. In the USA double mastectomies have been performed on children as young as 12. Children who commence puberty blockers at Tanner Stage 2 universally progress onto wrong sex hormones, which incontrovertibly leads to infertility and sexual dysfunction as adults. Puberty is the stage of development that allows humans to reach sexual and reproductive maturity. It stands to reason that if this does not occur, this maturity does not occur.
Dr Marci Bowers, President-elect of WPATH, has raised concerns that all the males attending for surgery who were puberty blocked at Tanner stage 2 are anorgasmic. Dr Bowers has been ignored by WPATH, Dr Bowers’ own organisation.
Fertility preservation on children whose bodies have not matured has poor chance of success. Bone density issues are frequent. And the effects on brain maturation are a complete unknown.
The article also fails to mention that one of the collaborators on the chapter on Eunuchs, hosts a website called the Eunuch Archives, which hosts a private forum that discusses child sex abuse fantasies. That WPATH collaborated with this person, raises serious questions about their judgment.
I would urge all readers to be aware that this is not a straightforward issue. Independent review in progressive countries sees problems with this treatment pathway and more and more countries are shifting away. Read the Cass Review, a highly regarded independent report from a highly regarded paediatrician, and consider an alternative view point.
This article reads like a rearguard action to shore up local support for these protocols in the face of mounting doubts being expressed internationally about transgender medicine in children, most emblematically in the investigation and closure of the UK’s Tavistock Clinic.
Prudent clinicians in Australia might give pause for thought.