WHO Responds to Public Pressure on Transgender Health Guidelines

Some Clarification but Troubling Concerns Remain

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There was good news and bad news in the response of the World Health Organization to the widespread criticism of the composition of the Guideline Development Group for its proposed guideline on the health of trans and gender diverse people. There is an extended period for public comment and some clarification of the guideline’s goals. However, the overall process and in particular, the attempt to promote self-identification in health care, remains troubling.

The first bit of good news is that WHO agreed to extend the deadline for public submissions from January 8 to February 2. It is not clear whether the meeting scheduled for February 19 is still on. A concession like this from an insular international bureaucracy is exceptional and shows that the letter writing campaign and petition organized over the Christmas and holiday season had an impact.

A second  piece of good news is that Florence Ashley has withdrawn from the GDG due to a “scheduling conflict.” Ashley is a Canadian law instructor who argues that almost any form of psychological treatment prior to beginning hormone therapy is a form of conversion therapy. Ashley also has a flamboyant and provocative social media presence that attracted international attention. However, the majority of the GDG still has bias and conflict of interest as strong as Ashley’s even if they have the sense to be more discreet about it.

The rest of the response has been mixed. On January 15, 2024,WHO issued a Frequently Asked Questions (FAQ) that raises more questions than it answers. The composition of the Guideline Development Group may be the least of the problems with the process.

The FAQ says that the guideline will not cover children and adolescents, which in the circumstances, is good news. What is really interesting is that the reason WHO gives for excluding children and adolescents is that “the evidence base for children and adolescents is limited and variable regarding the longer-term outcomes of gender affirming care for children and adolescents” is a major embarrassment for supporters to medical transition of minors.

The problem here is that the FAQ does not say anything about the status of young adults. This is a group which, in other contexts, WHO has recognized as a special category. According to this WHO webpage “WHO defines 'Adolescents' as individuals in the 10-19 years age group and 'Youth' as the 15-24 year age group. While 'Young People' covers the age range 10-24 years.” Another WHO web page on Adolescents and Young Adults refers to the 10 to 24 age range with 10-15 being early adolescence and 20 to 24 as young adults. The Global Consensus Statement on Meaningful Adolescent and Youth Engagement refers to youth as between 15 and 24 years old.

Young adults are at particular risk of harm from inappropriate gender transition. They have reached the age of majority and have full legal capacity to consent to medical treatment. However, their cognitive capacity is not yet fully developed and medical professionals have a special responsibility to ensure that they are in fact giving informed consent.

Furthermore, many young adults will already have started medical transition as children or adolescents. A person who receives puberty blockers and cross sex hormones in childhood or adolescence may have different needs for ongoing hormone treatment from a person who only started transition after completing puberty.

Bias in Favour of Gender-Affirming Hormones

The FAQ explains that the guideline will deal with both gender affirming care and gender inclusive care. Gender affirming care is defined as follows:

In line with the 11th edition of the WHO International Classification of Diseases and Related Health Problems (ICD-11), gender-affirming health care can include any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity. Of note, these new technical guidelines on the health of trans and gender diverse people will not consider surgical interventions.

There is no explanation of why the guidelines will not consider surgery. It may be that the evidence of benefit from surgery is also limited and variable.

A good quality evidence based guidline for hormone therapy for adults (including young adults) would still be valuable. However, WHO does not appear to be interested in assessing the evidence on whether these interventions actually lead to improved health. Instead, it regards access to affirming care as a human right.

The FAQ refers to changes to the ICD-11 in 2022 which replaced the terms transsexualism and gender identity disorder with the term “gender incongruence” and moved the diagnosis from the chapter on mental and behavioural disorders to the chapter on conditions relating to sexual health. A FAQ on this change explains that, ”Inclusion of gender incongruence in the ICD-11 should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services.”

The approach WHO is taking can be seen in the WHO Guidelines related to self-care interventions which are referred to in the FAQ. One of the questions the guidelines considered was “Should self-administration of gender-affirming hormones be made available in addition to health worker administration?” (p. 54)

The literature review failed to locate any relevant studies on this question so the Guideline Development Group was unable to make a recommendation. However, they did make something called a “Key consideration” which reads:

• The principles of gender equality and human rights in the delivery of quality gender-affirming hormones are critical to expanding access to this important intervention and reducing discrimination based on gender identity.

• Transgender and gender-diverse people live within social, legal, economic and political systems that place them at high risk of discrimination, exclusion, poverty and violence.

• Research is urgently needed to support evidence-driven guidance.

The first paragraph is significant because it describes gender-affirming hormones as an “important intervention” and treats the question of access as a matter of human rights. In other words, WHO has already assumed, without the benefit of systematic review of evidence, that gender affirming hormones are beneficial and that access to them should be expanded. Erika Castellanos, who is a member of the current Guideline Development Group, was also a member of the GDG for this guideline and was also the lead researcher on the values and preferences report.

Self ID and Health Care

The concept of gender inclusive care raises an even larger problem. The FAQ defines it as follows:

Gender inclusive care refers to gender diverse people's inclusion in, and access to, all forms of health care, free of stigma and discrimination, facilitated by health policy, laws and/or health interventions.

This sounds innocuous in theory but what it means in practice is allowing males into health care facilities for women and girls based solely on self-identification.

Reem Asalem, the United Nations Special Rapporteur on violence against women and girls raised this issue in her letter to the director of WHO on January 4, 2024:

The question of legal recognition of self-identified gender must be evaluated with a different set of stakeholders—inviting both trans advocates as well as representatives of women’s and children’s rights. These two sets of questions—the question of the provision of hormones and the question of legal recognition of self-identification of gender identity—are entirely different and they should not be conflated into a single process. The two must be untangled before the process proceeds further.

The whole question of self-identification remains controversial within the United Nations and its various agencies. The UN Universal Declaration of Human Rights does not make any reference to gender identity. Gender identity based on self identification is endorsed in the Yogyakarta Principles which are simply non-binding recommendations by a small group academics and activists. Robert Wintemute, one of the authors of the Principles, has since criticized them for failing to consider the potential harm that results from allowing fully intact males access to female only spaces.

The UN has an Independent Expert on Protection Against Violence and Discrimination on the Basis of Sexual Orientation and Gender Identity has  issued a Report on Gender: The Law & Practices of Exclusion. The Expert has issued numerous comments on law and policy including a letter on the Gender Recognition Reform (Scotland) bill which claims, “Within the United Nations Human Rights System, there is consensus on the imperative of legal recognition of gender identity and on the related standard of self-identification…”

This position is contradicted  by a letter from the Special Rapporteur on Violence Against Women and Girls. She also issued a follow-up statement defending her stand.

WHO has issued Guidelines related to HIV, viral hepatitis and sexually transmitted infections which contain the statement “For trans and gender diverse people, the legal recognition of preferred gender and name may be important to reduce stigma, discrimination and ignorance about gender variance.” (p.18) However, there is nothing about self-identification in the formal recommendations.

The effect of the inclusion of self-identification in the guideline scope is to use a process which is intended for scientific and clinical issues to advance a position which is a political and human rights issue. The process and the composition of the GDG means that the voices of women and girls whose right to bodily privacy in a health care setting will be infringed, will not be represented.