Recently released documentation of internal discussions between members of the World Professional Association for Transgender Health, including authors of WPATH’s Standards of Care, reveal profound ignorance and lack of concern for the harms and lack of evidence for gender medical and surgical interventions, and a shocking disregard for medial ethics.
The WPATH Files
Leaked internal discussions between WPATH members were published as the WPATH Files by the think tank Environmental Progress, because of their concern about the influence of WPATH on the policy and practice of transgender health care around the world, and the potential harm, especially to children and young people of the poorly evidenced and unethical policies advocated by WPATH.
The World Professional Association for Transgender Health (WPATH) enjoys the reputation of being the leading scientific and medical organization devoted to transgender healthcare. WPATH is globally recognized as being at the forefront of gender medicine.
However, our report shows that the opposite is true. Newly leaked files from WPATH’s internal messaging forum, as well as a leaked internal panel discussion, demonstrate that the world-leading transgender healthcare group is neither scientific nor advocating for ethical medical care.
Executive Summary WPATH Files
disturbing revelations
The WPATH Files press release summarises the concerns, which you can read about in detail in the full published document.
In the WPATH Files, members demonstrate a lack of consideration for long-term patient outcomes despite being aware of the debilitating and potentially fatal side effects of cross-sex hormones and other treatments. Messages in the files show that patients with severe mental health issues, such as schizophrenia and dissociative identity disorder, and other vulnerabilities such as homelessness, are being allowed to consent to hormonal and surgical interventions. Members dismiss concerns about these patients and characterize efforts to protect them as unnecessary “gatekeeping.”
WPATH files press release
what is wpath?
WPATH stands for World Professional Association for Transgender Health. It makes bold claims to be an authoritative evidence based organisation.
The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the primary functions of WPATH is to promote the highest standards of health care for transgender and gender diverse people through the Standards of Care (SOC).
WPATH SOCv8 FAQs
WPATH claims to be “gold standard”
The SOC-8 contains clinical guidelines meant to provide the gold standard on how to deliver care that is informed by both the existing evidence and broad expert multidisciplinary global consensus.
ibid
And that its advice is evidence based:
Research indicates that gender-affirming care for TGD adolescents improves overall health and well-being including building self esteem improving overall quality of life. Conversely, risks for not providing gender-affirming care for TGD adolescents can yield negative mental health outcomes including increased substance use and increased rates of suicidality
ibid
It sounds authoritative, and has been taken to be so by many medical organisations around the world, yet few have questioned WPATH and its credentials. In fact it is an organisation of self appointed “experts” and non medical activists who have for decades promoted medical hormonal and surgical intervention to minors and adults to change their bodies secondary sex markers. Our website FAQ on WPATH goes into more details.
evidence base still being assembled
Robert Garofalo, chief of adolescent medicine at the Lurie Children’s Hospital in Chicago, WPATH member and one of the authors of WPATH SOC7 told a podcast interviewer in May 2022 that the evidence base remained “a challenge . . . it is a discipline where the evidence base is now being assembled” and that “it’s truly lagging behind [clinical practice] in some ways.”
Only now, I think, are we really beginning to do the type of research where we’re looking at short, medium, and long term outcomes of the care that we are providing in a way that I think hopefully will be either reassuring to institutions and families and patients or also will shed a light on things that we can be doing better.
Robert Garofalo
So, even in 2022, a leading member of WPATH admits the evidence base is still being assembled. Yet that does not stop WPATH claiming to be an “evidence based” organisation and making strong recommendations about medical and surgical interventions for gender questioning children, adolescents and adults that many countries around the world, including the UK, are following.
strong claims based on weak evidence
WPATH recommendations do not fulfil the criteria for good guidelines: they are not based on rigorous systematic reviews of the evidence and do not link recommendations to an evaluation of the strength of evidence. In short, WPATH makes strong claims based upon weak evidence.
A systematic review and quality assessment of international clinical practice guidelines for gender minority/trans people published in the British Medical Journal in 2021 graded all available guidelines for transgender health care, including the WPATH Standards of Care 7, This was the first systematic review using a validated quality appraisal instrument of international Clinical Practice Guidelines addressing gender minority/trans health. The reviewers concluded that the WPATH guidelines could not be considered “gold standard” and they could not recommend their use. The reasons included a weak evidence base, lack of methodologicalical rigour, lack of editorial independence, and failure to grade recommendations according to the quality or strength of available evidence. (in other words strong recommendations were sometimes made based on weak evidence.)
A follow up article in the BMJ by the authors of the systematic review commented on the updated WPATH Standards of Care version 8 to say that it had not remedied the faults identified in SOC version 7,
It appears WPATH expects readers to faithfully accept potentially biased judgments of the literature rather than confidently submitting SoCv8 to open scientific scrutiny. SoCv8 could have been much better: its evidence base and recommendations cannot yet be relied upon.
An article by Jennifer Block in the BMJ in 2023, Gender dysphoria in young people is rising—and so is professional disagreement gave an account of what is meant by evidence based guidelines quoting noted experts in the field, and discussed how WPATH guidelines failed to measure up.
The BMJ article quotes Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario where he explains that “trustworthy guidelines…are based on systematic review of the relevant evidence,” for which there are also now standards, as opposed to a traditional narrative literature review in which “a bunch of experts write whatever they felt like using no particular standards and no particular structure.”
Mark Helfand, professor of medical informatics and clinical epidemiology at Oregon Health and Science University, says, “An evidence based recommendation requires two steps.” First, “an unbiased, thorough, critical systematic review of all the relevant evidence.” Second, “some commitment to link the strength of the recommendations to the quality of the evidence.”
Helfand said that for a treatment recommendation to be able to call itself “evidence based” it should mean both that the treatment has been systematically studied and that there is high quality evidence to support its use.
Helfand examined the recently updated WPATH Standards of Care and noted several instances in which the strength of evidence presented to justify a recommendation was “at odds with what their own systematic reviewers found”, for example one of the WPATH systematic reviews found the strength of evidence for the conclusions that hormonal treatment “may improve” quality of life, depression, and anxiety among transgender people was “low,” and also that “it was impossible to draw conclusions about the effects of hormone therapy” on death by suicide.
Yet, despite this weak or absent evidence, WPATH recommended that young people have access to gender affirmative treatments because the “emerging evidence base indicates a general improvement in the lives of transgender adolescents.” WPATH also asserted that there was strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures and that they were “safe and effective at reducing gender incongruence and gender dysphoria.”
It is the lack of connection between the strength of the WPATH recommendations and the quality of the evidence that is the fundamental weakness in the WPATH guidelines.
In their more honest moments WPATH members admit as much.
examples of issues of concern from the wpath files
Here are some excerpts from the files where members discuss the inability of children to comprehend the profound and life altering effects of gender affirming hormone therapy; the difficulties in advising young people and getting consent about the potential loss of sexual function and fertility; whether one should recommend irreversible medical and surgical treatments to people with severe mental illness; and discussions about evidence or lack of evidence for risk and long term outcomes of treatment. There is a lot that they admit to not knowing (thus demonstrating their awareness of the lack of evidence, despite WPATH’s claims), but also a lot they admit to knowing – such as that children cannot consent to loss of fertility and sexual function.
A prominent WPATH member, Dianne Berg, who is a child psychologist and co-author of the child chapter of the 8th version of WPATH’s Standards of Care (SOC8), said, of children and young adolescents, it is “out of their developmental range to understand the extent to which some of these medical interventions are impacting them.”
What really disturbs me is when the parents can’t tell me what they need to know about a medical intervention that apparently they signed off for.
Dianne Berg
shocking but not surprising
As indicated by the BMJ articles cited above, there was already ample evidence that WPATH was not what it claimed to be and should never have been used as a reliable resource for policies, practice and training worldwide.
Those of us who already knew this background were not surprised by the revelations in the WPATH files. But nevertheless we were shocked: witnessing health care professionals revealing that they are aware that young people cannot give consent to sterility and loss of sexual function, or admitting they believe the hormones they are prescribing may be causing liver tumours, or admitting to prescribing hormones or performing surgery on people who are mentally ill or cognitively challenged, is very chilling indeed. Hearing it straight from the horse’s mouth is a disturbing experience because it makes one wonder how health care professionals can be so unethical, so cavalier about safety and consent, so unconcerned about the lack of evidence for what they are doing or the long term outcomes for their patients.
why does it matter? WPATH influence in uk
WPATH is the leading organisation worldwide in advocating for gender transition medical interventions. It has been hugely influential in shaping UK policy, practice and medical training in the field of transgender healthcare. See this summary by Sex Matters.
The question for us as clinicians, patients and members of the public is how can medical organisations have been so captured that they did not question WPATH and allowed it to shape their national health policies, protocols and training? The serious flaws in WPATH have been known about for years, yet many government and clinical organisations, charged with making safe evidence based policy for the nation, did not do even the minimum due diligence on WPATH.
For example the NHS England service specification for adult gender clinics cites WPATH as providing useful “good practice” guidelines on psychology and hormone prescribing (pp 29 and 30).
The NHS England service specification has a section on speech and language therapy (p.7) which cites the Royal College of Speech and Language Therapy guidance which references WPATH as an authority.
The General Medical Council references WPATH standards of care version 8 as a useful resource.
The British Medical Association cites the WPATH standards of care as setting out “broad principles for supportive care of transgender and non-binary patients transgender and non-binary patients”
The Nottinghamshire Healthcare NHS Foundation Trust Centre for Transgender Health cites WPATH in its advice to GPs.
In its 2013 Good Practice guidelines for the assessment and treatment of adults with gender dysphoria, the Royal College of Psychiatrists referred to WPATH’s standards of care as an example of the sorts of “good clinical practice” that “have informed these UK standards of care”.
Scottish Government
In 2012 the Scottish Government wrote a Chief Executive Letter (which had to be followed) to health boards with the Gender Reassignment Protocol for Scotland:
“The protocol incorporates recommendations from the 7th edition of The World Professional Association for Transgender Health (WPATH) Standards of Care, September 2011. The protocol sets out those procedures which may be provided on the NHS; procedures exclusive to gender reassignment should be accessed via this protocol.”
In 2021, the update to the protocol advised the use of WPATH’s guidelines as a reference point. “The updated GRP should also take into account relevant international guidance including the World Professional Association of Transgender Health (WPATH) Guidelines.”
Welsh Government
The LGBTQ+ Independent Expert Panel commissioned by the Welsh Government wrote recommendations in a March 2021 report in which WPATH is cited several times. In one of these, it is described as the source of “authoritative international clinical guidelines” that “support the use of puberty blockers for trans youth, as one component of a holistic model of care”.
Many of the panel’s recommendations were carried through to the Welsh Government’s 2023 LGBTQ+ action plan.
The Welsh Health Specialised Services Committee is responsible for commissioning gender identity services in Wales. Its Specialised Services Commissioning Policy: CP182a Policy Gender Identity Service for Adults (Non-Surgical) says the policy should be read “in conjunction with” WPATH SOC7 and cites WPATH as a source in its “evidence” section.
Challenges to WPATH’s dominance and influence
WPATH’s influence in the UK and some other countries began to wane as a result of systematic reviews of the evidence for gender affirming treatments of children and young people (Finland, Sweden, England, Germany, and the state of Florida in the USA).
For example the Cass interim review recommends a move away from an affirmative approach, and the NHS interim service specification for gender services for children and young people says:
The clinical management approach should be open to exploring all developmentally and psychosocially appropriate options for children and young people who are experiencing gender incongruence. The clinical approach should be mindful that
this may be a transient phase, particularly for pre-pubertal children, and that there will be a range of pathways to support these children and young people and a range of outcomes.The primary intervention for children and young people who are assessed as suitable for The Service is psychosocial (including psychoeducation) and psychological support and intervention
NHS England Interim Service Specification
This interim service specification from NHS England is very different from the affirmative medical approach adopted by previous youth gender clinics, notably the Tavistock GIDS, influenced as it was by WPATH. The final service specification is due after the final Cass report, expected in April, and is likely to make the same recommendations. Unfortunately Scotland is yet to follow this wise path.
WPATH still influences adult gender services treatment protocols in England, the Scottish and Welsh governments, and several important medical professional bodies such as the GMC, RCPsych, RCGP and BMA, as well as training guides for doctors.
It is a sad reflection on the state of medical evidence based care, and especially in relation to transgender health, that the scholarly critiques of WPATH had little impact on the standing of WPATH and its use by medical organisations in the UK and around the world. It took some brave clinicians such as Professor Riittakerttu Kaltiala in Finland and Dr. Hilary Cass in the UK to start asking questions and investigate the lack of evidence for gender affirming medical interventions that has led to change.
breaking the chain of trust
As clinicians we cannot practise safely unless we can trust the integrity of the advice we are given by those who claim to be providing ethical and evidence based guidance. It is impossible for every clinician to read all the literature and research about an area of medicine or health care where they are recommending a course of treatment. This is especially important in transgender medicine where most of the hormonal treatments are off-licence which means that the prescriber takes responsibility for outcomes of treatment, including adverse effects. As the WPATH Files executive summary explains:
The contents of the WPATH Files are of utmost importance because WPATH has broken the chain of trust in gender medicine. Trust in professional training grounded in robust scientific evidence is crucial for doctors, who face time constraints that prevent exhaustive investigation of every treatment protocol. Influential organizations such as the American Academy of Pediatrics and The Endocrine Society rely on WPATH’s “Standards of Care” when developing policy and practice guidelines for the treatment of gender dysphoria.
Similarly, parents and vulnerable patients depend on clinicians influenced by WPATH. The truth about WPATH, as revealed in the Files, is therefore essential for patients, including parents of trans-identified minors, to make informed decisions about their medical treatment.
WPATH Files Executive Summary
Many influential medical organisations in the UK are still relying on WPATH’s Standards of Care, which have proven to be untrustworthy. This chain of trust has to be remade, if clinicians in the UK are to have any confidence in the advice we are getting from our professional bodies. Now that WPATH has been exposed, once again, to be unscientific, poorly evidenced and weak on medical ethics, shall we see these bodies abandoning reference to WPATH as a source of expert guidance in their policies, practice and training materials? We hope so, indeed we expect no less, if we are to be able to practise safe effective care for all our patients.