The World Professional Association for Transgender Health (WPATH) has recently published the 8th version of its Standards of Care. This will have major implications for the work of psychologists and therapists, well beyond those specialising in gender identity clinics. Peter Jenkins provides a detailed critique of the WPATH 8 guidelines and challenges their claim to present a model of best practice in this highly contested field.
WPATH 8: Standards of Care
This is a shameful document, by any standard. Any illusion that the issuing body, the World Professional Association for Transgender Health (WPATH), is in any way a credible professional body, with patient wellbeing at its heart, should be dispelled by the task of reading through the 180 pages of this guidance. The recommendations are carefully hedged about with multiple exceptions, so that the overall purpose for patients can still be achieved: “to better align their body with their gender identity” (Coleman et al, 2022: S31). The standards of care are carefully geared to achieving this end goal.
The term gender identity has no valid objective criteria and therefore no scientific, medical or legal value. It is the cornerstone, however, of this flawed rationale for practice. This narrative is presented as encompassing people who are Transgender and Gender Diverse (TGD), with gender identity at its core. Gender identity is presented as if it is innate, pre-social and naturally evolving and emerging over time. A surprising addition to the lengthening list of gender identities is that of eunuch, listed here with reference to a peer-support website, the Eunuch Archive. This has been exposed by Gluck (2022) as a repository of child pornography, specialising in fantasies of self- or child-mutilation. The inclusion of eunuch as a legitimate gender identity captures the process at work, where declassifying paraphilia (formerly Scoptic syndrome in DSM-4) seems intended to normalise fetishistic behaviour for a wider professional audience. The close nexus between social media, pornography and bodily mutilation (in the strict medico-legal sense) which is inherent within the concept of gender identity could not be made any clearer.
Barriers to care
The guidelines are based on a heavily over-socialised model of mental health (S7). Gender identity emerges and evolves as part of a naturally occurring phenomenon. Social responses to this gender identity are constructed as binary, i.e. either being fully supportive, or simply discriminatory and thus causative of minority stress. Barriers to care (s43) are perceived to take various forms, including stigma, limits to resources and medical gatekeeping via the constraints imposed by medical diagnostic procedures. (See figure below):
Figure 1: Schematic summary of WPATH 8 Standards of Care
Overall, the guidelines present a normative pathway towards transition, which is partly impeded by negative social pressures. Thus “Some health care providers, secular or religious organizations, and rejecting families may undertake efforts to thwart an adolescent’s expression of gender diversity” (S53: emphasis added: PJ). The term ‘thwart’ is perhaps unintentionally revealing here. It suggests a malign attempt to prevent a naturally occurring psychological and physiological process, as if it was a seedling growing towards the light as part of a phototropic growth process.
As part of the window display of good practice, the guidelines make frequent reference to the value of comprehensive assessment based on a multi-disciplinary team, of active parental support, and of the positive role of contextual support in schools and communities. However, it is clear these factors may well be desirable, but somehow they are not actually considered to be essential to the process at hand. For example, it is suggested that non-supportive parents can be bypassed where necessary, and their reluctance to provide consent over-ridden (S58, S62). The guidelines recommend that co-existing mental health conditions, such as autism, should be carefully assessed, but need present no permanent barrier to progressing children and adolescents along the treatment pathway (S37). Even suicidality should not present a barrier to progression (S63). At every turn, WPATH’s concept of best practice is systematically undermined by the irresistible twin pressures of autonomous client healthcare choices and, ultimately, by professional discretion to progress treatment as being in the patient’s best interests. The crucial barrier to care of age limits is also dispensable within these guidelines (S66). The unspoken dynamic driving the process is clearly a bias towards the presumption of treatment, rather than of non-treatment (Soh, in Lane, 2022). As the guidelines state: “…choosing not to implement potentially beneficial care services risks harm to a child” (S66).
Harm reduction measures
The structure of the guidelines disguises the key role of an underlying framework justifying these highly risky medical interventions. This is the model of harm reduction measures, derived from other contexts, such as the use of methadone for heroin users, needle exchange schemes, and supervised use of blades for the management of self-harm. Medical intervention for eunuchs, for example, is also justified within this model as reducing the risk of unregulated self-mutilation (S90). In ethical terms, this relies crucially on ‘a lesser evil’ argument. Hence medical interventions, such as providing breast binders for children, can cause harm, but this risk can be outweighed by benefits such as “increased comfort, improved safety, and lower rates of misgendering” (S54). This persistent motif, namely of trading high risk of physiological damage in exchange for claimed psychological benefit, is a central and recurring feature of these guidelines, and, perhaps, of gender identity affirming care more generally.
However, the harm reduction model applied here is simply aspirational, namely based largely on value judgements, but without hard evidence of its efficacy in the form of randomised controlled trials (RCT). This is clearly the case with puberty blockers, where the desired effect of delaying an unwanted puberty is supposed to minimise the claimed harm of psychological distress. However, there are no RCTs at present in relation to puberty blockers. The defensive argument applied here is that it would be unethical to deprive a control group of this beneficial medication (Deutsch et al, 2016).
Hostility to randomised controlled trials
At one level, this hostility to randomised controlled trials powerfully illustrates the claim to exceptionalism which is so central to gender identity affirming care. This resistance to scientific method clearly demonstrates its radical divergence from established norms for medical research and practice. At another more pragmatic level, the argument in favour of puberty blockers simply lacks compelling evidence. Thus, a NICE review in the UK found that the evidence for the wider benefits claimed for puberty blockers to be of low quality (NICE, 2021). This highly critical review of puberty blockers’ efficacy is, predictably, not cited in the guideline’s references.
Referencing on other key topics also seems selective and partisan, for example in relation to the vexed problem of detransitioners. The growing numbers of detransitioners rather spoil the guidelines’ optimistic narrative of careful assessment leading to successful outcomes in terms of transition. The frequency of detransition is dismissed here as ‘rare’ (S41, S42), but this claim is contradicted by a carefully framed study which suggests a detransition rate of 7-10% of adults attending a UK gender clinic (Hall et al, 2021).
This all points to a major structural problem with the guidelines, namely the profound weakness of their research and evidence base. Despite claims of being based on the best available evidence and on expert opinion, the guidelines rely on multiple outcome studies rather than on randomised controlled trials (CAN-SG, 2022). RCTs are normally considered to be the gold standard in medical and therapeutic research. The authors are forced to acknowledge this with respect to the so-called Dutch model, which is taken as justifying its model of assessment and treatment for young people. However, the original sample size (n: 55) quoted for the original research is far too small to justify the adoption of the Dutch model as an international standard of care (de Vries, 2014). Critics have pointed out, for example, that this survey’s outcomes were based on non-comparable groups of participants (Kaltiala, in Lane, 2022). The guidelines therefore sit uneasily on an inverted pyramid of research, resting precariously on a tiny sample of 55 participants, melded together with copious amounts of partisan expert opinion.
Why is this is relevant to therapists?
The WPATH 8 guidelines are relevant to therapists in a number of crucial ways. The Standards of Care are likely to be taken by the courts as presenting the carefully considered opinion of experts in the field, although this view is clearly open to challenge. Within the US medical insurance system, the guidelines are essential to validate insurance-funded gender identity affirming care, which is now a very lucrative and fast-growing market. Given the rising tide of class action litigation, both in in the US and UK, the guidelines are crafted in such a way that almost any professional decision to transition a child or adult can be legally protected via reference to WPATH 8, even where the decision is deemed to be ‘exceptional’.
It is perhaps tempting to see WPATH 8 as really representing a medical, rather than a psychotherapeutic perspective. This would be a mistake, for several reasons. The WPATH 8 Standards of Care provide the operational handbook for the principles of gender identity affirming care, set out for the US by the AMA (2018) and in the UK by the Memorandum of Understanding on Conversion Therapy (MOU, 2022). In medical clinics, such as the UK’s Tavistock Gender Identity Development Service, pressure to follow an affirmative model of therapy severely constrained opportunities for therapists to work in a more exploratory way with children and young people (Cass, 2022). Requiring psychological therapists to follow these guidelines means imposing major constraints their professional autonomy to practise according to their own preferred modality and established ethical precepts.
Finally, the rush to expedite medical transition ultimately makes therapy completely optional, if not totally dispensable, within this end-driven process. The value of therapy is briefly acknowledged, but then modified and brushed aside by WPATH. Thus, healthcare professionals are being encouraged to take on an advocacy role in order to promote a wider understanding of client needs (S79), with little consideration of how this may compromise their primary therapeutic role. Some counselling and psychotherapy may indeed be beneficial (S10), but it is not required by WPATH as a precondition for accessing gender identity affirming care (S31). In greasing the slipway towards medical transition, the WPATH 8 Standards of Care thus present a direct threat to the continued independence and autonomy of the psychotherapeutic professions.
American Academy of Pediatrics (AAP) (2018) Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. 142(4): https://pubmed.ncbi.nlm.nih.gov/30224363/
Cass, H. (2022). Independent Review of Gender Identity Services for Children and Young People: Interim Report. https://cass.independent-review.uk/publications/interim-report
Clinical Advisory Group on Sex and Gender (CAN-SG) (2022) What is WPATH and what are their guidelines? What is WPATH and what are their guidelines? – Clinical Advisory Network on Sex and Gender (can-sg.org)
Coleman, E. et al. (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 23:sup1, S1-S259. DOI: 10.1080/26895269.2022.2100644
de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014) Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. https://doi.org/10.1542/peds.2013-2958
Gluck, G. (2022) The Eunuch Archives. https://grahamlinehan.substack.com/p/genevieve-gluck-on-her-investigation
Hall, R., Mitchell, L. and Sachdeva, J. (2021) Access to care and frequency of detransition
among a cohort discharged by a UK national adult gender identity clinic: Retrospective casenote review. BJPsych Open, 7(6), e184, 1-8 doi: 10.1192/bjo.2021.1022.
Lane, B. (2022) Shaky foundations. Gender Clinic News. Shaky foundations – by Bernard Lane – Gender Clinic News (substack.com)
Memorandum of Understanding on Conversion Therapy (2022) https://www.bacp.co.uk/events-and-resources/ethics-and-standards/mou/
National Institute for Health and Clinical Excellence (NICE) (2020) Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_GnRH-analogues_For-upload_Final.pdf
Online petition against the WPATH 8 Standards of Care:
A petition open to UK citizens is being launched to request that the WPATH 8 Standards of Care not be implemented by the National Health Service: Please sign your name to it here.
By Peter Jenkins, counsellor, supervisor, trainer and researcher. He has been a member of both the BACP Professional Conduct Committee and the UKCP Ethics Committee. He has published a number of books on legal aspects of therapy, including Professional Practice in Counselling and Psychotherapy: Ethics and the Law (Sage, 2017).
Peter Jenkins is also a member of Thoughtful Therapists, whose scoping survey for the government consultation on conversion therapy can be found here.