The Case against Considering WPATH as a Competent, Reasonable Body of Expert Opinion
Disclaimer: The following article is not intended as legal advice. Please consult a lawyer if you are directly affected by any of the issues discussed below.
Medical transitioning of children and adults is one of the most serious healthcare scandals of our time, played out in full public view, but with very little informed media attention. Across the advanced world, the usual expectations of evidence-based medical care have been supplanted by a pre-scientific belief system, geared to moving patients as consumers along a pathway of increasingly severe medical and ultimately surgical interventions (Jenkins, 2022a;b). This is all done in the name of aligning bodily form with an inner gender identity. Patients dissatisfied with the partial results achieved are now looking to the law for redress, and are considering the option of suing for medical and therapeutic negligence on a grand scale. This article looks at the legal basis for bringing such actions. It mainly refers to the law relating to the UK, although the key principles will also apply within other legal contexts, such as the US and elsewhere.
One such potential litigant is Ritchie Herron in the UK, who is in the early stages of bringing such a case against the medical service responsible for surgery, claiming that it has resulted in lasting pain and physical discomfort (Harthan, 2022).
Criteria for medical negligence
The criteria for bringing a medical negligence case are straightforward to outline, if much harder to actually win in court. The court needs to be satisfied the the plaintiff’s case has been proven under the civil law test of ‘the balance of probability’. Translating the legal jargon, this means that it is probably the case, i.e. more likely than not, that the doctor was negligent, and that this action caused foreseeable harm to the patient as a result. This might sound very straightforward, but there is a huge medico-legal industry built around defending such cases, and it is relatively rare for medical negligence cases to succeed in court. (This article focuses primarily on medical negligence, and does not look at the related issues of capacity and informed consent in any detail.) Incidentally, it may well prove to be the case that therapists providing gender identity affirming therapy may prove to be much more vulnerable to negligence action than those healthcare practitioners who are providing access to medical transition. This vulnerability for therapists could arise from the relative lack of research validating gender identity affirmative therapy as a robustly evidence-based (as distinct from an ideological) stance towards their clients who identify as trans.
Individual legal cases can be extremely influential if they achieve the status of case law, as they then become the key point of reference on a given topic. Thus the Osheroff case against a psychiatric hospital in 1985 had a decisive effect in overturning fifty years of psychoanalysis as the dominant treatment modality within psychiatry in the US and across the globe (Aviv, 2022). Psychoanalysis was then replaced by a medical model informed by diagnostic criteria, and by treatment based on evidence-based interventions, such as medication and cognitive-behaviour therapy (Jenkins, 2007: 85-6). A single successful case of proven negligence, whether in the UK or elsewhere, against practitioners over medical transition could similarly lead to the rapid collapse of transgender healthcare as a thriving medico-financial enterprise.
Briefly stated, a case for medical negligence requires the plaintiff, i.e. the person bringing the case, to establish on the basis of clear evidence, that:
- the medical practitioner owed them a duty of care;
- there was a breach of this duty of care;
- the breach directly caused resultant foreseeable harm.
Harm can be both physical, e.g. impaired physical functioning, and/or psychological, i.e. causing a diagnosable psychiatric injury, such as clinical depression, post traumatic stress disorder, etc.
The wider political context is important here. Public awareness of the medical transitioning of children under 18, via the use of puberty blockers and cross-sex hormones at the Tavistock Gender Identity Development Service (GIDS), was largely sparked by a judicial review brought by Keira Bell in 2020. The Interim Cass Review (2022) then resulted in the closure of the Tavistock GIDS. This development is linked in the following video to the arguments for bringing a class action by larger numbers of patients who have potentially experienced harm caused by their medical treatment.
Class actions of this kind may be more common in other legal settings, such as Australia and the US, but are much less common in the UK (Pinsent Masons, 2022). There have been several failed class actions in the past on such issues as benzodiazepine prescriptions, and traumatic stress amongst military veterans.
Peer defence to a negligence case
So why is it so hard for medical negligence cases to succeed in court? This really is the nub of the question. People who feel they have been harmed by medical transition, including medication and sometimes surgery, may decide to detransition, and to seek compensation for the reduced quality of life they may now be experiencing. However, there is a major barrier to their winning negligence cases, in the form of the established system of peer defence which can protect doctors faced with litigation. To understand this, it is necessary to look briefly at some of the case law and how this works.
Medical negligence law is a well-established specialist field, peppered with signposts pointing out traps for the unwary, and defensive redoubts. One of these signposts points towards the Bolam test, which is the key reference point within the wider terrain. According to the Bolam test, a medical practitioner is judged according to “a standard of practice recognised as proper by a competent reasonable body of opinion”, i.e. which is accepted as proper by a “responsible body of medical men” (Bolam v Friern HMC ). If a medical practitioner can justify their decisions as having followed accepted and recognised practice, this then makes it much harder for a plaintiff bringing the case to prove negligence. Alternatively, if the practitioner has clearly deviated from recognised practice, this may make it easier for the plaintiff to win their case.
So what if the relevant standard of practice is wrong, out of date, or just makes no sense? A later ruling in the Bolitho case clarified that it is not sufficient for a doctor to simply refer to supporting expert opinion in order to defeat a negligence claim. The expert opinion referred to has to meet the high standard now imposed by the courts.
“Lord Scarman refers to a ‘respectable’ body of professional opinion. The use of these adjectives – responsible, reasonable and respectable – all show that the court has to be satisfied that the exponents of the body of opinion relied on can demonstrate that such opinion has a logical basis.” (Bolitho v City and Hackney Health Authority  at 778.)
WPATH as expert opinion?
In the field of gender medicine, the body of professional opinion which medical practitioners are very likely to rely upon in their defence is the World Professional Association for Transgender Health (WPATH) Standards of Care. This has already occurred in a lower court, where a General Medical Council Tribunal has determined that “WPATHSOC7 has the status of peer-reviewed expert guidance” (MPTS, 2022). In any future individual or class action cases, it is likely that medical practitioners (and therapists) will refer to WPATH Standards of Care (SOC), either versions 7 or 8, as justifying the particular course of action they have taken.
So our focus now needs to shift to WPATH and its Standards of Care. WPATH is a largely US-based organisation, comprising medical hospitals, universities and trans advocacy organisations. The mix of clinicians, researchers and trans advocates means that it is a “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). Despite this risk of apparent structural bias, WPATH wields enormous influence within the transgender healthcare field at a global level. It is, for example, deeply embedded within service contracts for both the Tavistock GIDS in London and the Sandyford Clinic in Edinburgh.
Any future litigation for medical negligence over children and adults transitioning will need to challenge and overturn the status of WPATH Standards of Care as peer-reviewed expert guidance. The Bolitho case described above sets out the key criteria for deciding whether professional opinion will be accepted by the court. The court needs to be convinced that the professional opinion relied upon is: competent; responsible; reasonable; respectable; and logical. All of these factors are intertwined to some extent, so that failing one test is likely to undermine another. If WPATH Standards are not competent, then it would be hard to see how they could also be considered reasonable, for example. One could also add that the Standards need to be ethical for good measure, although this is not strictly part of the Bolitho test as it currently stands in law. We will now look at WPATH with regard to three key areas, i.e. its model of medical practice; its record on research; and its stance on medical ethics.
WPATH’s model of medical practice
As a starting point, it needs to be said that the WPATH Standards of Care are not clinical guidelines, in the way that a non-professional observer might assume them to be. (See Table 1: Comparison of NICE clinical guidelines with WPATH Standards of care.)
Comparison of NICE clinical guidelines with WPATH standards of care.
|Criteria||NICE clinical guidelines:|
Clinician as expert.
|WPATH Standards of care: |
Patient as empowered consumer.
|Philosophy underpinning research orientation.||Materialist approach, investigation of physical and social worlds using positivist methodology.||Idealist, post-modernist approach,|
primacy of patients’ lived experience.
|Assessment process.||Differential diagnoses plus investigations, according to agreed criteria i.e. history, signs and symptoms.||Clinician affirmation of patient self-assessment, e.g. absence of set criteria for gender identity.|
|Treatment process.||Interventions according to best available evidence.||Facilitated progression on treatment pathway.|
|Preferred evidence basis for interventions.||Evidence-based practice e.g. randomised controlled trials.||Practice-based evidence e.g. cohort studies.|
|Feedback and evaluation process.||Audit and evaluation of service performance.||Limited evaluation and follow-up e.g. re attrition and detransition rates.|
Table 1: Comparison of NICE clinical guidelines with WPATH Standards of care.
NB: The above are representations of ideal types of clinical guidelines and of standards of care, so may not apply exactly in every instance.
The UK National Institute for Clinical and Health Excellence (NICE) issues clinical practice guidelines on a wide range of specific topics, based on the best available evidence, usually randomised controlled trials. Randomised controlled trials are specifically designed to identify causal factors which produce change, such as the impact of therapy in reducing symptoms of clinical depression. Diagnosis may be based on set criteria, so for example a patient self-score on the Patient Health Questionnaire 9 may be used along with other evidence to assess the severity of clinical depression, with scores less than 16 defined as less severe, and scores of 16 or more defined as being more severe (NICE, 2022: 7). Assessment of severity then informs appropriate treatment, including psychotherapy, anti-depressant medication, etc. Clinical audit and review is considered to be crucial for evaluating service outcomes.
In contrast, the Standards of Care rely crucially on patient self-diagnosis. This process derives from a pre-scientific paradigm, based on patient self-attribution of causal factors, which are not open to objective testing and verification. There are no agreed criteria for identifying a gender identity. The clinician is largely bound to accept (or, more rarely, reject) the patient’s perception of their lived experience, i.e. their personal sense of truth, as the key determinant for accessing treatment. The overall treatment goal is to “to better align their body with their gender identity” (Coleman et al, 2022: 31) via appropriate medication and surgery. In practice, this can mean facilitating the patient’s progression along a treatment pathway, which may lead to medication and surgery. Randomised controlled trials are rare, with a reliance on less authoritative observational cohort studies. Observational studies can identify changes over time, or between different groups, such as levels of satisfaction with interventions, but cannot isolate the causal mechanisms producing such changes. There may be also less emphasis on audit, evaluation and follow-up, so assessing rates of attrition or detransition may be correspondingly more difficult.
As expert peer opinion, NICE clinical guidelines also differ from WPATH in other significant respects. While NICE guidelines are not mandatory, they do set clear evidence-based standards. Thus the NICE guidelines on Depression advise against prescribing St John’s Wort, a herbal remedy, for depression, given the lack of evidence of its efficacy as treatment (NICE, 2022: 27) In contrast, WPATH Standards are written in such a way to afford the clinician systematic ‘workarounds’ for substituting the clinician’s professional judgement when clearly deviating from its recommendations (Jenkins, 2022a).
So, while WPATH best practice includes recommendations for multi-disciplinary teamwork, comprehensive assessment, supportive psychotherapy, full consideration of co-morbid factors, such as autism, risk assessment for suicidality and parental consent in the case of children and adolescents, in practice each of these requirements can be dispensed with, if this best meets the patient’s need for treatment and best promotes their autonomy. If all these ‘red flags’ are, in the end, completely optional, then it does raise the question of why have all these detailed recommendations of good practice, when they are each open to being abandoned when no longer thought to be convenient or necessary? The answer is perhaps suggested by comments made at WPATH Conference in September 2022 by Amy Tishelman, a senior figure in WPATH, and author of the key chapter on ‘Children’ in SOC 8.
The answer seems to be that WPATH Standards of Care 8 were carefully written in such a way to minimise the risk of litigation against clinicians. Unlike NICE, rather than constituting Standards of Care for the protection of patients, these appear to represent standards of protection for clinicians. If this is correct, it would follow that the one of the SOC’s main functions is to shield clinicians from litigation and thus to protect the perceived interests of the (largely US-based) transgender healthcare industry. The Standards do therefore not constitute evidence-based clinical guidelines which are in any way equivalent to the NICE guidelines. This must surely undermine any future claim for the Standards to qualify as reasonable and responsible expert peer opinion in a court of law.
WPATH’s record on research
If WPATH can claim to hold the status of expert opinion, then it would be reasonable to expect that it would take a proactive stance towards carrying out systematic reviews of the available evidence. It might also be reasonable to expect WPATH to commission randomised controlled trials wherever appropriate, in order to advance the evidence base for practice and to tailor its recommendations accordingly. However, this appears not to be the case. Chapter 6: Adolescents states: “Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead” (Coleman et al, 2022: 46).
With its 4,119 members and ready access to leading medical and university research libraries, it is puzzling how WPATH has taken the apparently easy route here, in opting for a brief narrative account of the Dutch protocol, rather than seek to evaluate the rapidly growing body of research on health outcomes for young people identifying as trans. However, faced with the same challenge, the Swedish SBU (2019) has been able to find 38 peer reviewed papers with primary data and carry out its own systematic review on gender dysphoria in children and adolescents. Over half the papers (21 out of 38) were listed in the references to SOC8, so these same references were presumably available, in theory at least, to the authors of SOC8 to carry out their own systematic review, had they been minded to do so.
Also in contrast with WPATH, NICE (2020; 2021) carried out two reviews of research into the effect of puberty blockers and gender affirming hormones respectively. The first review included 9 observational studies, 6 of which were included in SOC 8 references. The second review included 10 observational studies, 8 of which were included in SOC 8 references. WPATH was presumably aware of the vast majority of these studies, as these were cited in their own references in SOC 8 for 14 out of the 19 combined NICE review studies, and 21 out of 38 studies for the SBU survey. This raises the awkward question why WPATH was either unable or unwilling to carry out a systematic review of relevant studies, given that this had already been successfully carried out by both the SBU (Sweden) and NICE (England and Wales).
Besides the issue of failing to carry out a systematic review of available research, there is the related issue of the assessment of the quality of the research thus investigated. Both of the NICE reviews carried identical conclusions regarding the poor quality of evidence of the studies examined:
“The critical outcomes for decision making are impact on gender dysphoria, impact on mental
health and quality of life. The quality of evidence for all these outcomes was assessed as
very low certainty using modified GRADE “ (NICE, 2020: 4; 2021: 4).
The SBU conclusion stated:
“The literature on management and long-term effects in children and adolescents is sparse, particularly regarding gender affirming surgery. All identified studies are observational, and few are controlled or followed-up over time” (SBU, 2019: 2).
This raises a further concern that WPATH may have avoided carrying out a systematic review for precisely this reason, namely that the resultant findings could not stand as as evidence-based practice capable of justifying the SOC 8 recommendations.
Randomised controlled trials
It is striking that all the studies referred to by NICE and SBU are observational i.e. cohort studies, without any randomised controlled trials, normally the gold standard informing evidence-based medical interventions. In spite of this absence, there is no evidence that WPATH are now prepared to address this critical absence of supporting scientific studies. In fact, it appears that there are influential sections of WPATH who are resolutely opposed in principle to the idea of carrying out RCTs in the area of gender medicine.
Hence,“…individual RCTs might not always be feasible or ethically acceptable, including in transgender medicine and clinical research. For example, randomizing transgender people to receive or not receive hormone therapy would violate the principle of equipoise, the idea that there is true
scientific uncertainty about whether an intervention will benefit a patient-participant, since evidence suggests that hormone therapy is helpful at alleviating gender dysphoria…” (Deutsch, 2016: 1101).
The authors of this paper, Madeline B. Deutsch, Asa Radix and Sari Reisner, are all listed as members of WPATH, and are also listed as being amongst the primary authors of SOC 8. Their 2016 conclusions about the efficacy of hormone therapy in alleviating adolescent gender dysphoria are, of course, challenged by the more recent NICE and SBU survey findings. Rather than assume that hormone therapy is desired by young people and is, more importantly, effective, this is precisely what a randomised controlled trial needs to establish. This is now the position currently advocated by the Cass Review. However, WPATH (2022) has made clear its complete opposition to the Cass Review’s and NHS England’s proposals for carrying out such a research project, which it claims would violate patient autonomy. According to the model of medical practice outlined above in Table 1, WPATH clinicians would be likely to affirm their adolescent clients’ sense of gender identity; these adolescents may demand hormone therapy; selective reference to some observational studies suggests that hormone therapy is effective at reducing gender dysphoria; therefore, withholding hormone therapy as part of a randomised controlled trial would therefore breach adolescent autonomy to receive their preferred medication.
WPATH thus appears to be reluctant to carry out randomised controlled trials in the field of transgender healthcare, preferring the less authoritative research provided by observational cohort studies. It has also signally failed to carry out a systematic review of treatment and outcomes for adolescents, citing a lack of available research studies. However, two other professional bodies, NICE and SBU, have both carried out their own reviews within the recent period and have then acted on the findings to advise extreme caution with regard to medical interventions for young people with gender dysphoria. WPATH was aware of and had access to 21 out of the 38 studies cited in the SBU survey, and 14 out of the 19 studies cited in the two NICE surveys. WPATH clearly possessed the resources and capacity to carry out its own systematic review, but did not do so, at a time of intense international debate over best practice in transgender healthcare. It has also failed to cite the NICE and SBU surveys in its own SOC 8 references, suggesting a worrying tendency not to highlight unfavourable analyses. These failings would suggest that WPATH should not be considered to be a reasonable or competent body of expert professional opinion.
WPATH’s stance on medical ethics
The third aspect of WPATH is probably the most damaging to its claim to represent a competent and reasonable body of expert opinion. This concerns WPATH’s stance on medical ethics. Ethics may seem a dry, remote area of discussion, but they actually go right to the heart of the debate over transgender healthcare. WPATH (2020) is fond of repeating the phrase that ‘ethics is a conversation’, which sounds collaborative, inclusive and beyond reasonable challenge. However, ethics is emphatically not a conversation. Ethics is about establishing criteria for judging the outcomes of decisions, which can be seen to be justified or not. WPATH medical ethics are teleological, i.e. geared to producing a desired outcome, namely “to better align their body with their gender identity” (Coleman et al, 2022: 31). At each stage, gender affirming treatment is about facilitating the patient’s progress along a moving pathway towards transition. Hence providing breast binders appears to increase the patient’s desire for mastectomy by a factor of 19% (Julian et al, 2021: 1131); prescribing puberty blockers also correlates with increased likelihood of progression to cross-sex hormones (Bell v Tavistock (2021)). Withholding treatment would conflict with the predominant goal of body alignment and could be judged to be unethical, according to this goal-oriented ethical stance.
It is well known that the SOC 8 chapter on ethics was removed from the draft version. It is not clear how far its inclusion would have resolved concerns about WPATH’s ethical stance. What was notable was the inclusion of chapter on eunuchs as a gender identity. This follows on from the declassification of skoptic syndrome as a paraphilia in the DSM5. Hence in SOC 8, “eunuchs may also seek castration to better align their bodies with their gender identity” (Coleman et al, 2022: 88). As discussed above, WPATH medical practice is governed by the goal of bodily alignment, given “a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.” (Coleman et al, 2022: 90: PJ: emphasis added).
In terms of medical practice, the inclusion of eunuch raises a number of concerns. It is clear from its inclusion that there are no objective, verifiable criteria for this, or indeed, for any gender identity, other than those decided by people identifying as trans. Surgery to remove both testicles i.e. healthy, functioning tissue, is mandated here on the basis of a patient belief system, and justified by an untested model of harm reduction. The contrast with orthodox medicine could not be more marked, where deontological (i.e. rule-based) ethical principles still hold some sway, namely ‘First, do no harm’. Within evidence-based medical care, removal of testicles would only follow on from a specific diagnosis of testicular cancer, based on signs, symptoms and history-taking. Diagnosis would explore the least invasive treatment, based on research findings with regard to likely outcomes. Removal of both testicles is apparently rarely required in the case of testicular cancer (NHS UK, 2022). In contrast, WPATH displays a consistent bias towards medical intervention, in this case castration as an extreme form of radical cosmetic surgery, in order to comply with a patient’s sexual fetish. WPATH, of course, would deny any charge that such an operation would constitute cosmetic surgery, arguing that it would only be carried out as a medical necessity. However, all medical interventions within transgender healthcare must be categorised as a medical necessity, even in the relative absence of evidence of efficacy, simply in order to qualify for payment under the US healthcare insurance system: “Medical necessity is central to payment, subsidy, and/or reimbursement…” (Coleman et al, 2022: 17). Medical necessity and financial imperative seem to bleed together to form a single catch-all category at this precise point.
However, the most troubling aspect of the SOC 8 material on eunuchs lies in its apparent links to child pornography.
Genevieve Gluck goes on to describe in detail the website as a repository of child pornography, including multiple fantasies of castrating and mutilating children. This website is specifically referenced within WPATH SOC 8. It is not at all clear how this material can be justified in any way as a contributory part of developing medical standards of care. With regard to WPATH, this can not be accepted as being competent, responsible, reasonable, respectable and logical, i.e. the criteria required of expert opinion by a court of law. Above all else, if Genevieve Gluck’s information is correct, then WPATH’s actions here are shown to be both morally reckless and ethically indefensible.
WPATH Standards of gender identity affirming care are highly influential, both at a global level, and within the UK NHS. There has been a rise in interest amongst patients alleging harm caused by medical transition to sue for medical negligence, either as an individual or as a class legal action. Such cases are hard to win in court, largely due to an established system of peer medical defence, whereby medical practitioners can justify their decisions as being consistent with expert opinion. WPATH and its Standards of care are likely to provide the key reference point for medical practitioners facing such negligence action for medical transition in the UK and elsewhere. Case law requires that such expert opinion meets a high standard. The court needs to be convinced that such expert opinion is competent, responsible, reasonable, respectable and logical. The criteria are closely intertwined, so that failure in one aspect might well undermine others.
WPATH’s Standards of care are considered in three areas, i.e. their model of medical practice, their record on research, and their stance on medical ethics. It is argued here that, in each of these areas, WPATH and its Standards of care fail to meet the legal test of being competent, responsible, reasonable, respectable and logical. Furthermore, there is evidence that the Standards can also be considered to be unethical. If these arguments are taken to be correct, then the WPATH Standards of care would no longer provide a cast-iron legal defence for practitioners facing claims of negligence over medical transition in the future.
Aviv, R. (2022) “Psychiatry wars: The lawsuit that put psychoanalysis on trial”, The Long Read, Guardian, 11th October.https://www.theguardian.com/society/2022/oct/11/psychiatry-wars-psychoanalysis-antidepressants-rachel-aviv
Cass, H. (2022) The Cass Review: Independent review of gender identity services for children and young people: Interim report. https://cass.independent-review.uk/publications/interim-report/
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
Deutsch,M., Radix, A. and Reisner, S. (2016) “What’s in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care.” American Medical Association Journal of Ethics. 18(11) doi: 10.1001/journalofethics.2016.18.11.stas1-1611. journalofethics.ama-assn.org/article/whats-guideline-developing-collaborative-and-sound-research-designs-substantiate-best-practice/2016-11
Harthan, P. (2022) “Detransitioners – A Clinical Negligence Tsunami?” https://www.harthanbarrister.com/blog/files/44eca404b30952053e28c53829866deb-.html?fbclid=IwAR08ytvocU7RZMaeHJGw2RV30LuxY0KMZoGQxfQVI4_tpA-1-AOWVEjQlb4
Jenkins, P. (2007) Counselling, psychotherapy and the law. Second edition. London: Sage.
Jenkins, P. (2022a) “WPATH 8 Standards of care: 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/
Jenkins, P. (2022b) “’Get them on treatment’! WPATH and the long reach of US trans ideology into UK healthcare.” Critical Therapy Antidote, https://criticaltherapyantidote.org/2022/11/17/get-them-on-treatment-wpath-and-the-long-reach-of-us-trans-ideology-into-uk-healthcare/
Julian, J. et al (2021) “The impact of chest binding in transgender and gender diverse youth and young adults.” Journal of Adolescent Health. 68(6), 1129–1134. https://doi.org/10.1016/j.jadohealth.2020.09.029
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/
Medical Practitioners Tribunal Service (MPTS) (2022) Record of Determinations: Dr Helen Webberley:(3657058). https://www.mpts-uk.org/-/media/mpts-rod-files/dr-helen-webberley-30-jun-22.pdf
National Health Service (2022) Testicular cancer. https://www.nhs.uk/conditions/testicular-cancer/treatment/#:~:text=An%20orchidectomy%20is%20a%20surgical,full%20recovery%20are%20greatly%20improved.
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National Institute for Health and Clinical Excellence (NICE) (2021) Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria.https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_Gender-affirming-hormones_For-upload_Final.pdf
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Treatment and management. NG222. www.nice.org.uk/guidance/ng222
Pinsent Masons (2022) Class actions in England and Wales. Out-law guides.https://www.pinsentmasons.com/out-law/guides/class-actions-in-england-and-wales
Statens Beredning för Medicinsk och Social Utvärdering (Swedish Agency for Health Technology Assessment and Assessment of Social Services) (SBU)(2019) Gender dysphoria in children and adolescents: An inventory of the literature. A systematic scoping review. https://www.sbu.se/en/publications/sbu-bereder/gender-dysphoria-in-children-and-adolescents-an-inventory-of-the-literature/
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Legal References (UK)
Bolam v Friern HMC  2 All ER 118
Bolitho v City and Hackney Health Authority  3 WLR, 1151,  4 All ER 771 HL. http://www.bailii.org/uk/cases/UKHL/1997/46.html
R (Quincy Bell) and A v. Tavistock and Portman NHS Trust, and others  EWHC 3274https://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-and-portman-nhs-trust-and-others/
R (Quincy Bell) and A v. Tavistock and Portman NHS and others  EWHC Civ 1363https://www.judiciary.uk/wp-content/uploads/2021/09/Bell-v-Tavistock-judgment-170921.pdf
Legal References (US)
Osheroff v Chestnut Lodge (1985) 62 Md App, 519, 490 A.2d 720 (Md. Ct. App.).https://www.casemine.com/judgement/us/59148e81add7b049345553c5
This article is republished here by Critical Therapy Antidote by kind permission of Genspect: https://genspect.org/suing-over-medical-transition-the-case-against-considering-wpath-as-a-competent-reasonable-body-of-expert-opinion/
By Peter Jenkins, a counsellor, trainer, researcher and supervisor. He is a member of Thoughtful Therapists and the author of Professional Practice in Counselling and Psychotherapy: Ethics and the Law (Sage, 2017).