The medical transitioning of children has become one of the most controversial and polarising issues of our time. For some, it is a medical scandal. For others, life-saving treatment.
So, when hundreds of messages were leaked from an internal forum of doctors and mental health workers from the World Professional Association for Transgender Health, it was bound to spark interest. WPATH describes itself as an “interdisciplinary professional and educational organisation devoted to transgender health”. Most significantly, it produces standards of care (SOC) which, it claims, articulate “professional consensus” about how best to help people with gender dysphoria.
Despite its grand title, WPATH is neither solely a professional body – a significant proportion of its membership are activists – nor does it represent the “world” view on how to care for this group of people. There is no global agreement on best practice. The leaked messages (and the odd recording) – dubbed the WPATH files – are disturbing. In one video, doctors acknowledge that patients are sometimes too young to fully understand the consequences of puberty blockers and hormones for 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,” one Canadian endocrinologist says.
WPATH’s president, Dr Marci Bowers, comments on the impact of early blocking of puberty on sexual function in adulthood. “To date,” she writes, “I’m unaware of an individual claiming ability to orgasm when they were blocked at Tanner 2.” Tanner stage 2 is the beginning of puberty. It can be as young as nine in girls.
Elsewhere, there are extraordinary discussions on how to manage “trans clients” with dissociative identity disorder (what used to be called multiple personality disorder) when “not all the alters have the same gender identity”. Surgeons talk about procedures that result in bodies that don’t exist in nature: those with both sets of genitals – the “phallus-preserving vaginoplasty”; double mastectomies that don’t have nipples; “nullification” surgery, where there are no genitals at all, just smooth skin. And doctors discuss the possibility that 16-year-old patients have liver cancer as the result of taking hormones. The problem is not necessarily the discussions themselves, but that the organisation is not so open when speaking publicly.
The views of WPATH matter to the UK. For years, the organisation and its SOC have been cited as a source of “best practice” for trans healthcare by numerous medical bodies, including the British Medical Association and the General Medical Council – and still is. The Royal College of Psychiatrists refers to WPATH in its own recommendations for care.
Most relevant is that WPATH is cited as “good practice” in the current service specifications underpinning youth and adult gender clinics in England and Scotland, albeit in both cases it is WPATH’s previous SOC that is mentioned. The most recent version does away with all age limits from the beginning of puberty for hormones and surgical interventions, other than female to male genital surgery, and contains a chapter on eunuchs.
Several staff at England’s NHS adult gender clinics are not just members of WPATH (one is the former president), but authors of that current SOC. So too was Susie Green, the former boss of the young people’s charity Mermaids; a lack of medical expertise does not exclude either membership of WPATH or the power to influence policy.
England’s only NHS children’s gender clinic – the Gender Identity Development Service (Gids) at London’s Tavistock and Portman NHS Foundation Trust – will close its doors at the end of March, having been earmarked for closure since July 2022. But the 2016 service specification still underpinning Gids states that “the service will be delivered in line with” WPATH 7. While Gids was generally more cautious than other WPATH practitioners, clinicians I spoke to for my book, Time to Think, also relayed how young people claiming to have multiple personalities, or who identified with another race, could be referred for puberty blockers.
Gids staff have also presented at WPATH conferences for the past decade, including the most recent, held in 2022. This doesn’t imply agreement with WPATH’s principles, but association with the group becomes harder to justify as its views become more extreme.
It is difficult to see how the Department of Health’s assertion that NHS England “moved away from WPATH guidelines more than five years ago” holds.
What is true is that there is no mention of WPATH in updated guidance that will underpin the new youth gender services opening on 1 April. What’s more, NHS England has made it clear that WPATH’s views are irrelevant to its core recommendation that puberty blockers will no longer be available as part of routine clinical practice.
There is a battle raging over how best to care for children and young people struggling with their gender identity, with ever increasing numbers of European countries choosing to take a more cautious, less medical, approach after finding the evidence base underpinning those treatments to be wanting. NHS England insists that new services will operate in accordance with recommendations of the independent Cass review, and that it is well placed to develop policies “in line with clinical evidence and expertise”. But it won’t be easy. There is already discussion among professionals working in gender services planning a pushback against Cass’s as yet unpublished final recommendations.
It was difficult for Gids to stand up to external pressures, allowing the care it offered to suffer. At the same time, NHS England failed in its duty to provide proper oversight. Both they and those in charge of the new services must do better if they are to avoid the mistakes of the past. Without proper, evidence-based guidance on what good practice looks like, organisations like WPATH will continue to have influence.
• Hannah Barnes is associate editor at the New Statesman and author of Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children
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