The recent publication of WPATH Standards of Care (SOC), now version 8, has raised concern on a number of issues relating to proposed health and therapeutic care of people identifying as trans. These include the surprising addition of the term eunuch to a growing list of gender identities, with the latter’s source data being linked to an online repository of child pornography; the removal of age limits for children under 18 for undergoing medical treatment; and a more assertive stance on the promotion of trans affirmative healthcare. The role of WPATH SOC has come under scrutiny following adverse media coverage of the Sandyford Gender Identity Development Service for its inadequate research base and weak treatment protocols, which can be ultimately traced back to WPATH influence (Bell; Foster, 2022). While WPATH’s role in UK trans healthcare has received relatively little coverage to date, it exercises a significant influence over key providers, by providing the rationale, background research and underpinning values driving transgender healthcare provision in the UK. 

WPATH stands for World Professional Association for Transgender Health. It periodically issues Standards of Care, reportedly based on current research and peer expert consensus. However, while claiming to be a worldwide association, WPATH is clearly heavily dominated by the US. Thus, of 122 signatory organisations to the Standards of Care, 90 were from the US (See: Figure 1: Proportion of US agencies relative to rest of world).

Furthermore, WPATH signatories include a substantial proportion of agencies which are not medical or university institutions, but which are primarily trans advocacy organisations (see Figure 2: Proportion of medical and university institutions relative to advocacy agencies). Advocacy organisations from the UK would include Mermaids, as just one example. This blurring of boundaries between medical and university centres on the one hand and advocacy agencies on the other may lead to significantly different approaches towards clinical standards and research governance. Hence the WPATH might be best characterised, not as a professional association, but as an organisation where an activist agenda is increasingly evident. Thus “WPATH is a hybrid professional and activist organization, where activists have become voting members and have served as president. In fact, it can be argued that WPATH is activist-led rather than evidence-led” (MacRichards, 2019).

Although heavily dominated by the US, WPATH claims to speak as the leading authoritative body on trans healthcare at a global level. However, analysis of the various formats of the Standards suggests that these are not neutral, best-practice guidelines, but rather reflect key components of trans ideology as a complex belief system. Thus the Standards are based on:

• outcome-based ethical criteria for decision-making, with the ultimate end-goal being “to better align their body with their gender identity” (Coleman et al, 2022: 31) via appropriate medication and surgery;
• removal of perceived barriers to treatment, such as medical gate-keeping, diagnostic categories, need for prior resolution of co-morbid mental health conditions, etc;
• reliance on an unproven harm-reduction model, where the risk of immediate or longer-term physical harm is traded for short-term psychological benefits, via use of measures such as breast-binding, social transition, chest surgery and puberty blockers;
• denial of the relevance of age boundaries and associated safeguarding issues;
• an unsystematic stance towards data collection and research, characterised by reliance on a weak evidence base, hostility towards randomised controlled trials and a preference for endorsement by anecdotal lived experience.

These aspects of the Standards have been outlined in detail elsewhere (Jenkins, 2022) and will be illustrated in this article.

The UK provides relatively few signatory organisations to the Standards, totalling 7% of the total, and constitutes an even smaller percentage of WPATH’s individual membership. WPATH recorded individual membership currently stands at 4,119, with 75% of its membership being from the US.  This proportion corresponds closely with US overall organisational dominance, suggesting that USPATH might be a more accurate acronym for this organisation. The UK has a mere 93 individual members, constituting just 2% of the total membership. This membership can be roughly divided into professional categories, according to member qualifications (see Figure 3: Professional roles of WPATH UK members).  

From this brief breakdown of professional roles, it appears that almost half of WPATH UK members are in medicine, and a further quarter are involved in therapy, with a smaller proportion involved in nursing or speech therapy. While WPATH membership is relatively small in the UK, it is striking how WPATH links directly into key trans healthcare organisations within the UK. Thus WPATH UK membership includes senior figures leading advocacy organisations such as Mermaids and GenderGP, the Tavistock Clinic as the main provider of gender identity services for adults and children in England and Wales and of the MOU, i.e. the Memorandum of Understanding on Conversion Therapy. Membership also includes individuals linked to key private sector providers of trans healthcare, such as Gender Care, Gender Clinic, Gender Identity Clinic and the London Transgender Clinic (see Figure 4: WPATH links to key UK gender identity organisations).

This is not to suggest that WPATH controls the policy or day-to-day practice of UK gender identity organisations in any immediate or direct manner. But it would be fair to assume a high level of agreement, or at least a degree of convergence, with WPATH policy over a range of issues, given that membership is voluntary and is not a requirement of registration or practice in any given professional field. It will be argued below that this convergence with WPATH values can be identified in the practices of some of these key trans healthcare organisations, namely Mermaids, GenderGP, the Tavistock Clinic and the MOU.

Mermaids: Harm reduction via distributing breast binders

Mermaids is one of the main youth support and advocacy organisations for young people identifying as trans in the UK. The current CEO has spoken about obtaining puberty blockers from a specialist doctor in the US for her son, aged 12 years. Her son, Jack then underwent sex reassignment surgery in Thailand in 2014 at the age of 16. See below, Green, S. Transgender: A mother’s story. Ted X Talks, Truro

From a child safeguarding point of view, it is unlikely that this operation could have been authorised within the UK via his consent under s.8, Family Law Reform Act 1969. This type of operation for children under 18 is apparently no longer legal within Thailand.

Press reports have claimed that Mermaids staff provided chest binders to some young people seeking help, without parental knowledge or consent. Breast binding in relation to gender expression for clients identifying as trans is specifically referenced by the Standards version 7 applying at this time, i.e. “Breast binding or padding, genital tucking or penile prostheses, padding of hips or buttock” (Coleman et al, 2012: 10). The negative physical consequences of breast binding are further acknowledged in Standards version 8, as including “back/chest pain, shortness of breath, and overheating…More serious negative health impacts such as skin infections, respiratory infections, and rib fractures are uncommon and have been associated with chest binding in adults…” (Coleman et al, 2022: 54).

Breast binding is clearly an elective, i.e. voluntary, procedure, designed for cosmetic purposes, and is not medically indicated. The claimed benefits are largely psychological in nature, i.e. “increased comfort, improved safety, and lower rates of misgendering” (Coleman et al, 2022: 54). The WPATH rationale for their provision and use is based on the underlying philosophy of harm reduction, i.e. that breast binding may carry specific identifiable physiological risks, but that these can be minimised and traded off against claimed future psychological benefit. Presumably breast binding also serves to move the client along the path of increasing habituation and socialisation and into accepting the norms of transition. The Standards versions 7 and 8 do not reference any randomised controlled trials for the use of breast binders.

The philosophy of harm reduction is acknowledged as being central to the evolution of the Standards of Care (WPATH, 2021: 352). It is not surprising, therefore, that Mermaids have framed their justification of the use of breast binders in exactly the same terms, demonstrating their close  alignment with WPATH on their use: “Mermaids refused to comment on the investigation but said the charity took a “harm reduction position” on providing chest binders with safety instructions, so people did not have to turn to “unsafe practices” or experiencing dysphoria” (Sleator, 2022).

GenderGP: Minimising the role of medical gate-keeping

GenderGP is another trans advocacy organisation where another senior staffer is also an individual member of WPATH. It has been critical of the concept of medical gate-keeping to medical transition, as allegedly operated by General Practitioners and by the Tavistock Clinic. In 2021, the Daily Telegraph ran two reports on GenderGP. A reporter, posing as a 15 year old girl, was able to obtain a prescription for testosterone gel (or ‘T’) after just two Skype appointments with counsellors and one Skype appointment with a doctor at its online clinic. GenderGP reportedly offers a gender identity affirming model of care, based on assessing ‘stage, not age’. In a further case, reporters, posing as parents of a 12-year old boy, were reportedly informed by the lead counsellor at GenderGP, that the 12 year old could start on puberty blockers within six weeks, and begin taking cross-sex hormones within seven and a half months of starting with the clinic (TIT, 2021a, 20121b).

Reliance on a model of  assessing ‘stage, not age’ corresponds closely to the core principles of WPATH, i.e. that patient autonomy as a healthcare consumer is the primary driver for service provision, with minimal regard for medical gate-keeping. Briefly, young people aged 16-17 years in England and Wales with capacity can normally consent to most medical procedures, under s.8, Family Law Reform Act 1969. Young people aged under 16 can also consent to many medical procedures, including obtaining contraception or a termination of pregnancy if female, if deemed to have sufficient understanding under the Gillick test. The same principle as applied to medical transition was successfully challenged in court via judicial review by Keira Bell, a detransitioner, in December 2020 (see Jenkins, 2021 for a summary). GenderGP held a video discussion of the consequences of this initial overturning of Gillick with regard to medical transition several days after the ruling.

Hence, a senior counsellor at GenderGP can state the following (extract from, Gender GP (2020) “How is care for transgender youth impacted by the Tavistock and Portman ruling?”:

Counsellor: “What do we even mean by ‘able to give consent’? I’m not actually even sure that there is a litmus test that says ‘you can’ or ‘you can’t’. If you’re saying ‘you can’t give consent, well, how can you prove that? How could you prove somebody isn’t able to give consent? It just feels like a black hole!” (GenderGP, 2020: 11.23-24) (PJ: emphasis added).

It is concerning that a senior counsellor at GenderGP seemed unaware of the particular significance of the Gillick case for consent by under-16’s, and even of the effect of the first Tavistock decision itself. Somewhat ironically, given the remit of the discussion on Youtube, namely on, “How is care for transgender youth impacted by the Tavistock and Portman ruling?”, this senior counsellor seemed unaware of the very existence of Gillick. This approach towards minimising the role of medical gate-keeping with regard to accessing medication is entirely consistent with the key values of WPATH. Hence: “Early use of puberty-suppressing hormones may avert negative social and emotional consequences of gender dysphoria more effectively than their later use would” (Coleman et al, 2012: 20).

MOU: Another hybrid professional activist organization

The Memorandum of Understanding on Conversion Therapy is an inter-professional coalition of organisations committed to achieving a legal ban in the UK of conversion therapy on the grounds of sexual orientation and gender identity (MOU, 2022). The MOU has been signed by 29 major health and therapy organisations, including the NHS for England, Scotland and Wales, and is endorsed by a further 4 organisations. It closely parallels WPATH in blurring the boundaries between formal professional associations and activist lobbies by including Stonewall as an endorsing organisation. Stonewall is neither a professional association nor a provider of medical and therapeutic services. The Chair of the MOU has acknowledged the role of WPATH in positive terms. See video below of MOU, (2021) Therapists against Conversion Therapy: 4/11/2021

The phrase used here, “..for those of us who want to access transition, whatever age that might be, however young or however old” is rather telling. Unlike most professional codes of practice, e.g. BACP (2018), the MOU as a policy document does not distinguish between adults and children in any way.

Regarding the crucial role of assessment, the Chair of the MoU has argued against the “extended exploration of someone’s traumatised history” (Scottish Parliament, 2021). This is consistent with statements in WPATH, to the effect that “safety-related interventions should not preclude starting gender affirming care” (WPATH, 2021: 76). This stance is apparently justified on the basis of the “risk of harm induced through not providing care” (WPATH, 2021: 347, emphasis added: PJ).

However, exploratory therapy with young people identifying as trans is important, in order to help identify past trauma. This can then inform accurate risk assessment and risk management. For example identifying and exploring Adverse Childhood Experiences (ACEs) is particularly important in the case of therapy with young people identifying as trans, as their presence may heighten the risk of future self-harm or suicide (Scottish Government, 2018: 15). Awareness of ACEs can then contribute towards the therapist seeking to jointly mitigate the risk of self-harm and suicide by trans clients, for example by identifying protective strategies and resources, such as carefully negotiated safety plans. The MOU thus blurs crucial boundaries between professional lobbying and political activism, between the needs of children and adults, and minimises the need for safeguarding and careful risk management.

NHS Gender Clinics: Close alignment with WPATH Standards

Senior clinicians at the Tavistock Gender Identity Development Service in England also have individual membership of WPATH. However, the influence of WPATH within NHS England, Scotland and Wales is pervasive and systemic in nature, if little recognised until recently. WPATH is specifically referenced in the service contract for the Tavistock (NHS England, 2016: 2) and is referenced in the Sandyford Clinic Handbook (Greater Glasgow and Clyde NHS, 2014: 4). NHS practice in gender clinics parallels WPATH Standards in several respects, namely in terms of assessment procedures for children seeking treatment and in an unsystematic stance towards data collection and research.

In the case of the Sandyford Clinic, the assessment process for young people appears to be largely based on client self-report, according to a consultant clinical psychologist:

“Our primary function is to assess people for their readiness for treatment and to get them on treatment…The entirety of the assessment is based on that person’s self-report. We can only go on what they tell us. It’s not a forensic assessment where you’re looking at social work and school and all of those things. You’re basically just going on what they tell you. It is a massive concern, but that’s what it is at the moment, unfortunately” (Sanderson, 2022: emphasis added: PJ).

‘Get them on treatment’ might almost be WPATH’s main driving mantra. Because, if this is an assessment process being described here, then it is not at all clear exactly what is being assessed, and what are the exclusion criteria that might apply. Assessment is therefore a misnomer for what seems to be a circular and tautologous process, geared primarily to facilitating access to treatment. While the WPATH standards lay claim to the need for detailed multi-professional assessments, in practice there are numerous exceptions which undermine the need to follow this in practice. Hence “rigid assessment tools for “transition readiness” may reduce access to care and are not always in the best interest of the TGD person” (Coleman et al, 2022: 36).

This calls to mind the comments made about similar assessments and recording practice at the Tavistock GIDS: “Records of sessions with young people and their parents were often simply descriptions of discussions that had taken place. They did not include any analysis, structured assessment, professional curiosity or clinical decision making” (CQC, 2021: 23). The Tavistock GIDs apparently unsystematic approach to data collection, audit and analysis was the subject of unfavourable judicial comment on several occasions during the original Tavistock judicial review in 2020 (Bell v. Tavistock, [2020]).

The Standards make frequent reference to their being “based on the best available science and expert professional consensus” (Coleman et al, 2022: 5). However, the research base claimed by WPATH is lop-sided, partisan and increasingly open to doubt. According to one review, “…WPATH SOCv7 is based on lower-quality primary research, the opinions of experts and lacks grading of evidence” (Dahlen et al, 2021). Another critic claims that the “guidelines that were developed by people and organizations with conflicts of interest, with no systematic review, and with no evidence of safety or efficacy of treatment” (MacRichards, 2019). Crucial aspects of transgender healthcare, such as the provision of puberty blockers, are based primarily on outcome studies or case reports. This is in part because the Standards oppose medical gate-keeping which may provide a barrier to accessing treatment, and are welded to the operational principle of harm reduction. WPATH thus appears to be opposed in practice to carrying out randomised controlled trials into the relative effectiveness of puberty blockers or other key aspects of transgender healthcare.  

Conclusion

WPATH claims to be the leading global organisation setting standards for transgender healthcare. In reality, it is heavily dominated by the US in terms of organisational and individual membership. It blurs boundaries between medical/academic and advocacy organisations, and is best described as a hybrid professional and activist organisation. The Standards of Care are not neutral, evidence-based guidelines, but represent the cutting edge of trans activism in the field of healthcare, as endorsed by universities, medical and advocacy agencies. The Standards are based on outcome-based decision-making, geared to progressing clients along the pathway to social and medical transition, by removing barriers to treatment, rationalised via an unproven model of harm reduction. Age boundaries and associated safeguarding issues are consistently minimised in practice. Its research base is weak and over-reliant on outcome and case studies. Data collection and analysis of treatment pathways has been found to be cavalier and unsystematic in practice.

While WPATH individual membership is low in the UK, WPATH links into key transgender healthcare organisations such as Mermaids, GenderGP, and the main gender identity services within NHS England and Scotland. The MOU replicates key WPATH values, such as blurring the boundaries between professional associations and trans lobby groups, and between the therapeutic needs of adults and children, while minimising the need for careful risk management within exploratory therapy.

The WPATH Standards of Care are therefore not reputable guidelines and should be rejected. 

References

Bell, D. (2022) “I fear they are failing children with many complex problems”, Scottish Daily Mail, 31^st October. https://www.pressreader.com/uk/scottish-daily-mail/20221031/textview

British Association for Counselling and Psychotherapy (BACP) (2018) Ethical Framework for the Counselling Professions. Lutterworth: BACP. https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework-for-the-counselling-professions/

Care Quality Commission (CQC) (2021) Tavistock and Portman Clinic Inspection Report. https://www.cqc.org.uk/provider/RNK/inspection-summary#genderis   

Coleman, E. et al. (2012) Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7. World Professional Association for Transgender Health (WPATH). https://www.tandfonline.com/doi/abs/10.1080/15532739.2011.700873

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 https://www.wpath.org/publications/soc

Dahlen S, Connolly D, Arif I, et al. International clinical practice guidelines for gender minority/trans people: Systematic review and quality assessment. BMJ Open 2021;11:e048943. Doi:10.1136/bmjopen-2021-048943, https://bmjopen.bmj.com/content/11/4/e048943

Foster, K. “Children aged just 9 given puberty blockers”, Scottish Daily Mail, 31^st October. https://www.dailymail.co.uk/news/article-11376781/Puberty-blockers-given-children-young-NINE-Scotlands-Tavistock-Centre.html

Gender GP (2020) “How is care for transgender youth impacted by the Tavistock and Portman ruling?” 2^nd December.11.23-24, https://www.gendergp.com/trans-youth-healthcare-impacted-by-tavistock-portman-ruling-gendergp-livestream/ or https://www.youtube.com/watch?v=fvQFNl1wJs0

Greater Glasgow and Clyde NHS (2014) Sandyford Gender Identity Services. www.sandyford.org

Green, S. Transgender: A mother’s story. Ted X Talks, Truro: https://www.ted.com/talks/susie_green_transgender_a_mother_s_story?language=en

Jenkins, P. (2021) “Calibrating Gillick in the age of gender wars: Part 2: The curious case of the Tavistock.”  Critical Therapy Antidote, https://criticaltherapyantidote.org/2022/01/02/calibrating-gillick-in-the-age-of-gender-wars-part-2-the-curious-case-of-the-tavistock/

Jenkins, P. (2022) “WPATH 8: Greasing the slipway towards medical transition.” Critical Therapy Antidote, https://criticaltherapyantidote.org/2022/10/08/wpath-8-standards-of-care-greasing-the-slipway-towards-medical-transition/

MacRichards, L. (2019) “Bias, not evidence, dominates WPATH transgender standard of care.” Canadian Gender Report. https://genderreport.ca/bias-not-evidence-dominate-transgender-standard-of-care/

Memorandum of Understanding on Conversion Therapy (MOU) (2021) Therapists against Conversion Therapy: 4/11/2021: (Video): 15.40-18.40 https://www.youtube.com/watch?v=C6Yodbg3KY8

Memorandum of Understanding (2022) Memorandum of understanding on conversion therapy in the UK. https://www.bacp.co.uk/events-and-resources/ethics-and-standards/mou/

NHS England (2016) NHS Standard Contract for Gender Identity Development Service for Children and Adolescents. https://www.england.nhs.uk/wp-content/uploads/2017/04/gender-development-service-children-adolescents.pdf

Sanderson, D. (2022) “Sturgeon’s Tavistock backed by ‘little evidence’”, Daily Telegraph, 27^th October. https://www.telegraph.co.uk/news/2022/10/26/sturgeons-tavistock-clinic-offers-trans-children-surgery-not/

Scottish Government (2018) Scotland’s Suicide Prevention Action Plan. https://www.gov.scot/publications/scotlands-suicide-prevention-action-plan-life-matters/

Scottish Parliament (2021) Equalities, Human Rights and Civil Justice Committee: Conversion Therapy. Column 30. Meeting of the Parliament: EHRCJ/21/09/2021 | Scottish Parliament Website

Sleator, L. (2022)  “Trans charity accused of offering chest binders without parental consent”, The Times, 26^th September. https://www.thetimes.co.uk/article/trans-charity-accused-of-offering-chest-binders-without-parental-consent-x5smb3pvz

Telegraph Investigations Team (2021a) “Online clinic prescribes sex-change drugs to children without parents’ consent”; “How children can order life-altering transgender drugs from the bedroom”, Daily Telegraph, 27th February. https://www.telegraph.co.uk/news/2021/02/28/exclusive-online-clinic-willing-prescribe-sex-change-drugs-children/

Telegraph Investigations Team (2021b) “No doctor’s meeting for sex-change drugs”, Daily Telegraph, 1st March. https://www.telegraph.co.uk/news/2021/02/26/children-can-order-life-altering-transgender-drugs-bedroom/

World Professional Association for Transgender Health (WPATH) Draft Standards of Care: Version 8: https://www.docdroid.net/file/download/bJLGHdZ/wpath-soc8-draft-for-public-comment-no-watermarks-pdf.pdf

Legal references

Gillick v. West Norfolk AHA [1985] 3 All ER 402; [1986] AC 112 https://www.bailii.org/uk/cases/UKHL/1985/7.html

R (Quincy Bell) and A v. Tavistock and Portman NHS Trust, and others [2020] EWHC 3274 https://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-and-portman-nhs-trust-and-others/

---

By Peter Jenkins, counsellor, trainer, researcher and supervisor. He is the author of Professional Practice in Counselling and Psychotherapy: Ethics and the Law (Sage, 2017).