Disreputable Opinion

Can the medical profession and courts trust the WPATH SOC8?

One of the challenges the courts face in medical malpractice cases is defining a standard of reasonable care in areas where there is uncertainty or disagreement. The test applied in English and Canadian cases is whether the course of treatment in question is supported by “a body of reputable opinion.” Today, this often refers to formal clinical guidelines and standards of care.

The Standards of Care of the World Professional Association for Transgender Health (WPATH) are often referred to as defining the standard of care in gender medicine but, when you look at the machinations around the most recent edition, it is doubtful that they should be considered reputable opinion.

On September 6, 2022 WPATH published the 8th edition of its Standards of Care (SOC8) in the International Journal of Transgender Health. The journal is a partner organization with WPATH and many of the authors of SOC8 are on the editorial board.  The original version of SOC8 set out recommended minimum ages for certain procedures on children and adolescents, including:

• 14 for hormone treatment (estrogens and androgens);

• 15 for chest masculinization (removal of girls’ breasts);

• 16 for breast augmentation and facial surgery;

• 17 for “bottom surgery” including metoidioplasty (construction of a neo-penis from the clitoris), orchidectomy (removal of testicles / castration), vaginoplasty and hysterectomy and frontal-orbital remodelling;

• 18 for phalloplasty

In each case the age recommendation was qualified with the phrase “unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.”

Just 9 days later WPATH published a Correction which removed these minimum ages entirely. The rationale for the change was explained by Amy Tishelman, the lead author of the child chapter, at the WPATH conference in Montreal. Some of her comments are reported by Christina Buttons in this report from the Daily Wire:

“We were thinking, and it was scary for me, about the potential uses of the chapter for legal and insurance contexts,” said Amy Tishelman, who introduced herself as the lead author of the Child chapter in WPATH’s new guidelines. “What we didn’t want to do was create a chapter that would make it more likely that practitioners would be sued because they weren’t following exactly what we said.”

“We wanted there to be some clinician judgment without being at risk for being held in court for not sticking completely to these standards,” continued Tishelman. “So we did write them in a way I think so that there is leeway, that we recommend things, but we suggest that clinicians use their judgment about what to do in therapy situations and assessment situations so that they can use individualized clinical judgment and not face malpractice suits.”

These are appalling statements from a representative or an organization which claims to be dedicated to improving patient care. One of the goals of clinical standards of care is to help avoid malpractice litigation. But they are supposed to achieve that goal by making recommendations based on the best available research so that doctors can avoid causing the harm that might lead to a lawsuit. Instead, WPATH is leaving guidelines deliberately vague so that doctors who are sued will find it easier to avoid liability. It is doubly appalling when one considers that the patient group in question are children.

This attitude was consistent with some of the patchy history of the organization. WPATH was founded as the Harry Benjamin International Gender Dysphoria Organization. It was named for Dr. Harry Benjamin, an endocrinologist with a history of promoting dubious cures. In 2006 it was re-branded as the World Professional Association for Transgender Health, with a mission that included both political advocacy and promotion of evidence-based care. The membership of WPATH includes both medical and psychological professionals and activists with no clinical training.

The scientific and political goals of WPATH have been in conflict, with activists seeking to suppress scientific results that conflicted with their preferred agenda This agenda has consisted of stigmatizing any attempt to treat gender dysphoria through psychological means as “conversion therapy” and removing barriers to accessing medical transition. The conflict between science and activism came to a head at the 2017 congress when protestors blocked presentations by Dr. Ken Zucker.

While the WPATH Standard of Care are widely assumed to he the standard for gender medicine, they have never been accepted as actual clinical guidelines. There are established procedures for creating a reliable guideline and WPATH falls short on several counts. The 7th edition of the WPATH Standards of Care was created without a systematic evidence review and through a process that had large potential conflicts of interest and  an outside assessment rated it as low quality.

SOC8 was supposed to represent a new start. The revision process was to include and evidence review team and require disclosure of conflicts of interests.  It is questionable how far these good intentions were carried out. The work group for the chapter on children included Susie Green. Ms. Green has no qualifications in medicine or clinical psychology. She is the founder of the U.K. based lobby group Mermaids, which promotes medical transition of children and youth.

When the draft SOC8 was released in October 2021 it received criticism from all sides. Many critics were concerned that the minimum ages for some procedures had been reduced while others objected to any age standards.

One area of special concern was a new chapter on eunuchs. Critics noted that the chapter referred to a website on castration fantasies which hosted over 3,000 pornographic stories, many describing the rape and castration of children. The reference to this website can still be found in Chapter 9 of the Standards of Care. I will not link to it here and I strongly recommend against accessing it on a computer at your school or workplace. This is probably the only instance of an international medical organization referring to a source of hard-core pornography in its standards of care.

All of this could be dismissed as an ad hominem argument. Attacking the character and motives of the WPATH team does not prove that their conclusions are false. However, while ad hominem is a fallacy in formal scientific debate, it is a practical necessity in day-to-day decision making. Judges, policy makers and practicing doctors do not have the time or the qualifications to conduct a footnote-by-footnote scientific assessment of each clinical guideline they may have to consider.

Instead, lay people look at whether the source the advice is trustworthy. Organizations and individuals build trust by giving advice based on rigorous and unbiased scientific review. They forfeit trust if they act through tainted motives (eg. Helping members avoid lawsuits) or show obviously poor judgment (eg. Referencing pornography web sites).

WPATH has disqualified itself as a source of trustworthy advice. Unfortunately, this may not have an immediate effect in the court room. WPATH clinicians have impressive credentials on paper and it would be difficult to present some of the material in this article in a trial governed by strict rules of evidence.

Change will need to start at the clinical and public policy level. There is a pressing need for reliable standards of care in gender medicine and WPATH has demonstrated that it is not a fit organization to provide them. Health authorities around the world need to follow the lead of Finland, Sweden and the United Kingdom and  develop standards of care which are genuinely evidenced based.