BREAKING Extended deadline for feedback on development of a WHO guideline on the health of trans and gender diverse people. Submissions now close 2 Feb 2024
In June 2023, the World Health Organisation (WHO) announced it was planning to develop a guideline on the health of trans and gender diverse people; a further notice on 18 December 2023 gave details of the guideline development group meeting that had been rescheduled for 19-21 February 2024, including a list of the guideline development group members.
The Clinical Advisory Network on Sex and Gender (CAN-SG) is a network of clinicians from different regulated healthcare professions mainly in the UK and Ireland with an interest in the impacts of sex and gender on healthcare, including clinicians working with trans and gender diverse people. We have the following concerns about WHO’s proposed guideline process.
Assumption that gender-affirming care is safe and effective
The WHO announcement states that the guideline “will provide evidence and implementation guidance on health sector interventions aimed at increasing access and utilization of quality and respectful health services by trans and gender diverse people”, and will focus on “the provision of gender-affirming care”. This appears to assume that gender-affirming care is a safe and effective management approach. This assumption is incorrect.
Amongst clinicians and policy makers globally, there is growing concern about the long-term efficacy and safety of these interventions. People who have received these interventions and experienced harmful effects, or who have subsequently de-transitioned, are speaking out. We are concerned that this announcement gives the appearance that WHO has taken a policy position on this without critically appraising the evidence.
CAN-SG notes that the gender-affirming medical approach has been abandoned by Finland, Sweden and England explicitly in children and adolescents because of the uncertainty about the benefits and likelihood of harm. We understand that there may be many underlying factors that lead people to seek healthcare for gender dysphoria or gender-related distress. We think that every person seeking care deserves compassionate and thoughtful assessment, and treatment that is backed by high-certainty evidence. There are no robust randomised-controlled trials supporting gender-affirming medical and surgical interventions, and therefore there are no studies which tell us about the efficacy of these interventions, in children or adults.
Self-determined gender identity has harmful public health consequences
Self-determined gender identity is often framed in terms of the human rights of trans and gender diverse people. However, there is emerging evidence that this has serious public health implications for other groups in the population, particularly women, children and adolescents, and the concept is now contested. For example, the UK Government consulted the public in 2019 about reform of the Gender Recognition Act 2004, and abandoned plans to adopt a policy of self-determined legal sex after an unprecedented level of opposition from women’s rights groups.
There are consequences for society when people claim access to the rights of the opposite sex. This is multi-faceted, and places the highest burden on the most vulnerable women and girls, challenging their human rights. This includes women in prisons, in hospitals, in care, in mental health settings, women accessing services following domestic or sexual violence, and those that are dependent on other people for intimate care. These are all people whose healthcare WHO should be championing, particularly noting WHO’s vision for healthcare systems that “leave no-one behind”.
There are also profound implications for health systems and research, particularly with regard to data collection and resource allocation. WHO is clear that access to data that is disaggregated by sex is critical to the understanding of gender inequity in health, and the delivery of equitable healthcare. Allowing people to self-determine their sex in official documents and records can undermine accurate data collection, and therefore undermine efforts to tackle inequity, including the inequity trans and gender diverse people experience. WHO has a responsibility to consider the rights and needs of all groups when formulating guidelines. We are doubtful that this guideline development group will do that.
The perspectives of the guideline development group are biased
International organisations promoting gender-affirming medical interventions, and the right to replace sex with self-determined gender identity in law and policy, such as the World Professional Association for Transgender Health (WPATH) and Global Action for Trans Equality (GATE), are strongly represented in the guideline development group. There are now many clinicians and service users around the world questioning the evidence supporting gender-affirming medical interventions, or who have experienced harm or regret after receiving them. These groups are not represented at all. This means that the panel will not be able to make recommendations based on balanced perspectives, which is of particular concern given the paucity of evidence on several critical questions in this field. The lack of any representation from the increasingly visible cohort of people who have received gender-affirming medical interventions and experienced harm or regret, and those who have detransitioned, is very concerning. The WHO Handbook for Guideline Development recommends that service users are involved in guideline development groups to ensure that the “critical outcomes are identified and prioritised” and “the balance of benefits and harms of the intervention is appropriately considered when recommendations are formulated.” In excluding representation from detransitioners and women from the vulnerable populations profoundly impacted by the consequences of self-identification, this guideline process appears to fall short of WHO’s own guidance.
Out of the eight clinicians on the guideline development panel, five have held prominent positions in WPATH. WPATH have been criticised for the poor quality of their clinical practice guidelines, which lack clear evidence to decision-making frameworks, and at times make recommendations that run counter to the evidence they present.
WHO is trusted the world over to produce reliable guidelines that take a human rights approach to promoting health equity. Given the rising controversy in this field, it would appear that WHO is out of touch with developments globally. We urge WHO to pause this guideline and rethink its approach.
WHO is consulting on the composition of the Guideline Development Group until 2 Febuary 2024. Comments should be sent by email to hiv-aids@who.int.
CAN-SG statement on the proposed WHO guideline for the health of trans and gender diverse people
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