In the light of disclosures in a current court case in the USA that implicates the World Professional Organisation for Transgender Health (WPATH) leaders in research malfeasance, CAN-SG wrote to the World Health Organisation (WHO) to express concerns about the reputational risk to WHO from the continued influence of WPATH in its transgender health guideline development group (GDG).
We had previously written to WHO about bias and inadequacies in its guideline development process but the recent revelations about WPATH are of even greater concern.
The lawsuit disclosures reveal that WPATH leadership went to great lengths to suppress the systematic reviews they themselves had commissioned from Johns Hopkins University (JHU) because the reviews concluded there was little or no evidence to support the WPATH plans to recommend wide access to hormones and surgeries for all those who desired them. WPATH forced JHU to withdraw the completed manuscripts that did not meet WPATH’s desired conclusions, and then required that WPATH would have to approve all future publications by JHU related to the project.
This undermines the necessary independence and credibility of academic inquiry and calls into question WPATH’s motives and integrity.
WPATH leaders who are named in the unsealed documents include members of the current WHO transgender health guideline development group. Ten of the 26 GDG members are associated with the World Professional Association for Transgender Health (WPATH), and several hold or have recently held leadership positions in the organisation.
In our letter (below) we urged WHO to consider suspending the guideline process and re-evaluating both the scope of the guideline and the range of stakeholders informing this work. We believe there is a serious reputational risk to WHO if this process is allowed to continue.
CAN-SG Letter to WHO June 2024
Director
Global HIV, Hepatitis and STI Programmes
World Health Organization
We are writing to you as the Clinical Advisory Network on Sex and Gender (CAN-SG), a group of UK and Ireland based clinicians calling for greater understanding of the effects of sex and gender in healthcare. We work with policy makers, providers and health professionals and stay up-to-date with developments in gender healthcare.
We wrote to you in January 2024 pointing out that your guideline documentation on the health of trans and gender diverse people was problematic in that it assumed that gender-affirming care is safe and effective. We expressed concern that you were not aware that self-determined legal sex has potentially harmful public health consequences; and noted that the perspective of the guideline development group is biased.
We note that the work on WHO’s guideline for the health of trans and gender diverse people is continuing. We note that the six new additions to the guideline development group are intended to “enhance the group’s range of expertise, specifically in endocrinology, bioethics, mental health, and health policy/service delivery”. We also note that the scope of the guideline appears to remain unchanged.
We remain concerned about the process and want to draw your attention to further developments in the field that reinforce the substantive reputational risk to WHO and this guideline group in continuing on this path, producing a guideline document that is unbalanced and not informed by current evidence.
SAFETY of GENDER AFFIRMING INTERVENTIONS
Firstly, we remain concerned that it appears that the evidence for the safety and efficacy of gender affirming medical interventions will not be assessed directly in this guideline development process. The stated focus on interventions including the “provision of gender-affirming care, including hormones relating to adults” implies that WHO has assumed that gender-affirming care is beneficial, and this guideline will examine evidence relating to interventions aimed at promoting provision of this care. We believe WHO has an obligation to scrutinise the evidence for hormonal treatments in this population in line with WHO policy and ensure that it does not produce a guideline promoting interventions that are not underpinned by a reliable evidence base.
We agree with WHO that trans and gender diverse people are entitled to full protection of their human rights, including the right to the highest attainable standard of mental and physical health, and therefore it is essential that medical interventions with significant adverse effect profiles and irreversible impacts on multiple body systems should be subject to full evidence review in the proposed guideline. It does not follow that it is beneficial to trans and gender diverse people to recommend interventions to enhance access to treatments that may in fact be harmful to them, or for which the evidence of benefit is unclear.
Over the past years several young people who have been harmed by gender-affirming care around the world have spoken out and some have initiated litigation against care providers who prescribed them hormonal treatments. Increasing numbers of detransitioners are speaking publicly about their experiences, and the harms they have suffered. Research in this area is sorely lacking, but it seems likely that liberalised access to gender-affirming care may lead to increased numbers of people who subsequently regret certain interventions, suffer adverse effects, or decide to detransition despite making irreversible changes to their bodies. Some of our member clinicians work with detransitioners clinically and see the impact of this in their practice daily. We had a panel of speakers on this issue at our conference in March this year, including Ritchie Herron who is a detransitioned 35-year-old who began transition in his twenties (see clips from this event here). You are obliged to make a full, independent, transparent systematic review of evidence of long term harms of these policies.
However, you have appointed a guideline development group with an overwhelming majority of advocates for gender-affirming care, and there does not appear to be anyone in the group who would advocate for the needs of detransitioners, or people who have experienced harm from gender-affirming care. You need to include clinicians that have experience in this group of patients, and detransitioners themselves, in your decision making.
Alliance with WPATH
Further, we note that ten of the 26 guideline development group members are associated with the World Professional Association for Transgender Health (WPATH), and several hold or have recently held leadership positions in the organisation. WPATH produces Standards of Care (SOC) for the care of trans and gender diverse people, and it acts as an advocacy organisation for gender-affirming care.
In our previous communications with you we highlighted the criticism WPATH has received for the poor quality of its own guideline development processes. Since January, the public has seen further evidence that WPATH has been operating in ways that undermine patient safety, evidence-informed practice, and the core ethical principles of medicine with the publication of the WPATH files, leaked documents from WPATH’s internal listserv. The details in these documents cast major doubts about the influence WPATH has in this field, and WHO should note that the NHS in the UK has dropped reference to WPATH´s SOC from its revised guidance on youth gender services. Of particular relevance to you and this WHO guideline, further information has come into the public domain recently that implicates WPATH leaders in research malfeasance.
WPATH AND RESEARCH MALFEASANCE
As part of disclosure in a current court case in the USA, emails pertaining to the commissioning of researchers at Johns Hopkins University (JHU) by WPATH to perform systematic reviews and support evidence synthesis for SOC8 have been unsealed. WPATH leadership went to great lengths to suppress the systematic reviews because the reviews’ conclusions did not support the WPATH plans to recommend wide access to hormones and surgeries for all those who desired them, firstly by forcing JHU to withdraw the completed manuscripts that did not meet WPATH’s desired conclusions, and then by requiring that WPATH would have to approve all future publications by JHU related to the project. We understand that media coverage of this story is imminent, and that further documents will be unsealed in the coming months with further details of this controversy. WPATH leaders who are named in the unsealed documents include members of the current WHO guideline development group.
We urge you to consider suspending this guideline process and re-evaluating both the scope of the guideline and the range of stakeholders informing this work. We believe there is a serious reputational risk to WHO if this process is allowed to continue.
We would very much welcome further discussion with you about these matters.