The history of medicine can be read as a continuing struggle between individuals or movements introducing innovative techniques and organisations favouring rule-based caution. In his classic novel Madam Bovary, Gustave Flaubert provides the cautionary tale of a village doctor who is persuaded to make a name for himself by undertaking a radical new approach for surgery on his patient’s deformed feet.
“He had lately read of a marvellous new treatment for club feet…’What risk is there?’ he asked Emma. ‘Look!’ – and he counted the ‘pros’ on his fingers. ‘Success, practically certain. An end of suffering and disfigurement for the patient. Immediate fame for the operator” (Flaubert, 1981:186.) The naïve doctor persuades his even more gullible patient to undergo the experimental treatment, which quickly results in the onset of gangrene, requiring the amputation of the patient’s leg in order to avoid a fatal outcome.
Heroic surgery
Medical history is full of similar examples of heroic or charismatic surgery, which is very high risk for patients, but is spurred on by potentially higher gains for the doctors involved. In the UK, we have the examples of Bristol Royal Infirmary, with a mortality rate over the period 1991–1995, probably double the rate in England at the time for children under one year (Kennedy, 2001: 5); and Alder Hey Hospital in Liverpool, where a leading doctor falsified crucial medical reports and was engaged in the unauthorised retention of children’s organs during the period 1988-1995 (Redfern, 2001: 86). Medical technique clearly needs to progress and develop, but there needs to be a careful scaffolding in place of ethical standards and public accountability, to make absolutely sure that patient risk is minimised in the process.
Given this context, the recent release of The WPATH Files raises major concerns about the apparent lapse of ethical standards in the highly contested field of gender medicine. The WPATH Files comprise a tranche of leaked emails of internal discussion by WPATH members about difficult treatment options for their transgender patients. This deluge of concerning emails is placed in its historical, social and medical context by its author, Mia Hughes. She details the rapid rise of demand for gender transformative surgery in recent decades, and its provision by a host of gender clinics, particularly in the US. The World Professional Association for Transgender Health (WPATH) has established itself as the leading global authority in the field, claiming its Standards of Care as authoritative, evidence-based standards across the world.
Behind the WPATH façade
Yet, behind the façade of sober medical professionalism and cutting-edge medical practice, not all is quite as it seems with WPATH. Even the title is based on persuasive definition, rather than on settled reality. WPATH claims to be a World organisation, but, in reality, two thirds of its membership are from the US. The claim to be a Professional Association is in serious doubt, given that around a third of its members are trans activists or allies, rather than qualified medical professionals. The WPATH Files also challenge its claim to effectively promote Transgender Health, given its apparent reluctance to ‘gatekeep’ access to medication and surgery, and perceived resistance to carry out systematic audit, evaluation and follow-up to its interventions. The vaunted WPATH Standards of Care appear carefully crafted to offer maximum protection for health practitioners from litigation, rather than to safeguard patients. The Standards are in no sense comparable to medical practice guidelines issued by reputable professional bodies such as the UK National Institute for Health and Clinical Excellence (NICE).
WPATH signature practices
WPATH’s signature practices arguably mark it as offering experimental medical (i.e. hormonal and surgical) treatment for a psychological condition, namely gender distress. The following distinctive features mark its approach as resting on a uniquely consumer-led model of care, possibly more analogous in many ways to the cosmetic surgery industry, than to traditional medicine or psychiatry:
- 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 (Jenkins, 2022).
Gender affirming care as medical negligence?
So what do the WPATH Files add to our knowledge of how gender affirming medicine operates? The Files provide a cogent analysis of how WPATH emerged with all the trappings of professional body, but is driven by a trans activist agenda of removing restrictions on access to gender medication and surgery. In short, WPATH is alleged to provide “consumer-driven extreme body modification masquerading as medicine” (Hughes, 2024: 50), thus constituting “one of the greatest crimes in the history of modern medicine” (Hughes, 2024: 70). The report firmly places gender affirming care in the context of a long and inglorious heritage of medical negligence scandals within the US and UK, including such passing medical fashions as lobotomies, ovariectomy, height restricting interventions and surgery for an amputation fetish (pp 53-70).
The distinctive element of the WPATH Files consists of the leaked emails and video recorded internal discussion of members discussing problematic cases. The emails suggest a worrying gulf between WPATH’s reassuring public stance, as the beacon of good practice, and the less than impressive reality of apparently anecdotally-driven decision-making on the hoof. Thus, the following comment from internal discussion about the raw reality of gaining fully informed consent from adolescents, who are desperate to start puberty blockers and cross sex hormones, but which may well completely destroy their fertility: “it’s always a good theory that you talk about fertility preservation with a 14-year-old, but I know I’m talking to a blank wall” (Hughes, 2024: 12). The arguments favouringadolescents having the requisite cognitive development and emotional maturity to make such life-changing decisions were, of course, subject to devastating legal scrutiny in the Keira Bell judicial review of the UK’s Tavistock Gender Identity Development Service (R & A v. Tavistock [2020]).
The risks involved in minimising safeguards for children and vulnerable adults accessing major medical interventions are shown in another case, of working with an adult with claimed multiple personalities, which was discussed in a case presentation. Thus, “the patient had seven alters, two of which were “agender” and one female. “Alters were in agreement about surgery,” [the presenter] assured the audience” (Hughes, 2024: 45). Informed consent from a fluctuating set of alters might seem to be a questionable basis for authorising major surgery on a vulnerable adult.
Incongruence as a parallel process
From a therapeutic perspective, the WPATH Files demonstrate the almost entirely disposable role of therapy within gender-affirming care, except to provide a secure portal into medical intervention. There also seems to be a curious kind of parallel process at work here. The client’s experience of incongruence between their birth sex and preferred gender identity seems to be paralleled by the marked dissonance between the WPATH’s publicly professed confidence in its own statements on the one hand, and the hesitant, anecdotal state of internal discussion, confused rather than assisted by trans activists, on the other.
The release of the WPATH Files and the supporting email and video evidence must surely mark the point of no return for WPATH as credible organisation, although only successful litigation for medical negligence is likely to bring this sorry chapter of gender affirming care to its ultimate conclusion.
References
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
Flaubert, G. (1981) Madame Bovary: A story of provincial life. London: Penguin.
Hughes, M. (2024) The WPATH Files: Pseudoscientific surgical and hormonal experiments of children, adolescents and vulnerable adults. Albany, California: Environmental Progress. https://environmentalprogress.org/big-news/wpath-files
Jenkins, P. (2023) “Get them on treatment!” WPATH and the long reach of gender 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
Kennedy, I. (2001) Learning from Bristol: The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. https://www.bristol-inquiry.org.uk/final_report/the_report.pdf
Redfern, M. (2001) Royal Liverpool Children’s Inquiry Report. HC 12-11. London: Stationery Office. https://assets.publishing.service.gov.uk/media/5a74a0b5e5274a410efd121e/0012_ii.pdf
Legal reference
R (Quincy Bell) and A v. Tavistock and Portman NHS and others [2020] EWHC 3274https://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-and-portman-nhs-trust-and-others/
Commentary by Peter Jenkins who is also a member of Thoughtful Therapists, whose scoping survey for the UK government consultation on conversion therapy can be found here: https://thoughtfultherapists.org/scoping-survey-pdf/
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