Documents unsealed in a US lawsuit reveal that the World Professional Association for Transgender Health (WPATH) has suppressed publication of systematic reviews of the evidence on transgender health that WPATH had commissioned from Johns Hopkins University (JHU) because WPATH was not happy with the results. The reviews had found little or no evidence to support WPATH’s policies of promoting gender affirming medical and surgical interventions.
WPATH is a US based advocacy group. While it claims to be an evidence based professional organisation, it has been criticised for basing its recommendations on the opinions of activist and pro-affirmation clinicians rather than a rigorous appraisal of the evidence. Despite these weaknesses, that have been known about for several years, WPATH “standards of care” have been very influential in shaping transgender health care policies worldwide, including in the UK. The Cass Review found that almost all international guidelines are based on WPATH or Endocrine Society guidelines, both of which have influenced each other. Several WPATH members are on the World Health Organisation (WHO) guideline development group to produce WHO guidelines for transgender health care.
In addition to suppression of research, unsealed documents from another US court case reveal that WPATH removed all age thresholds for transgender hormonal and surgical treatments at the behest of a high-ranking Biden administration official, Assistant Secretary for Health Dr. Rachel Levine
Suppression of research findings
The following is a summary of the information about the suppression of research findings, taken from the publication by LGB Courage Coalition which also provides links to the unsealed documents, all of which are now in the public domain. More documents are expected to be unsealed in the coming months.
In 2022, the State of Alabama passed a law that bans medical transition services for under 18s and was promptly sued by ACLU. As a result of the lawsuit, last month a number of documents had to be produced by WPATH to the court regarding how their Standards of Care 8 (SOC8) were developed.
The email exchanges and documents related the relationship between WPATH and Johns Hopkins University (JHU), which was commissioned to review the evidence.
The documents reveal that the WPATH leadership went to great lengths to suppress systematic reviews (SR) commissioned from Johns Hopkins because the reviews’ conclusions did not support the WPATH plans to recommend wide access to hormones and surgeries for all those who desired them. The evidence suppression was achieved via a 2-prong strategy. First, WPATH forced JHU to withdraw the already completed and submitted manuscripts that did not meet the desired conclusions. Next, WPATH instituted a new policy whereby it would have to approve all future publications by JHU.
The new approval policy required that all reviews met a special WPATH checklist, which included items such as whether the review positively contributes to promoting transgender interventions, if it includes transgender people as authors, etc. WPATH required two rounds of approval—first, at the proposal stage, which had to approve the review’s anticipated conclusions, and second, at the final manuscript stage. WPATH reserved the right to alter the content. The new policy also required that final publication carry the disclaimer that WPATH had no influence over the process and that the views are solely by the JHU authors.
This post-factum “approval policy” led to a heated debate between WPATH and JHU, with JHU protesting undue WPATH interference and asserting its academic freedom and contractual ability to publish. But in the end, WPATH prevailed. The offending reviews that had led to the development of the approval policy were never published. Notably, only one review was ever published after the policy was put in place: Baker et al. (2021) review of hormonal interventions. The Baker SR is problematic: it did not evaluate any physical harms (despite the protocol stating so), and its pro-medicalization conclusions contradicted the review’s actual findings. The SR carries the disclaimer stating that WPATH had no role in the review, ironically using the exact language required by the approval policy. Internal documents confirm that Baker et al. went through the approval process.
The unsealed documents not only demonstrate that WPATH manipulated the evidence, but also show other problems (e.g., unmanaged conflicts of interest, activism-driven agendas, etc). More documents are expected to be unsealed in the near future, likely containing even more damaging info about WPATH’s credibility as an organization.
Cass Review
WPATH’s credibility has already been challenged, most recently by the Cass Review which found that WPATH guidelines lacked developmental rigour. The Cass Review said that the WPATH Standards of Care version 8 (SOC8) overstated the strength of the evidence in making its recommendations.
WPATH files
Prior to that the leaked WPATH files revealed disturbing discussions among WPATH members where, for example, they admitted that many of their young teenage patients could not give informed consent to the loss of fertility and sexual function that was caused by use of puberty blockers and cross sex hormones, as well as expressing concerns about unknown long term consequences and risks to health such as liver cancer.
British Medical Journal
A 2023 article in the British Medical Journal1 reported that Mark Helfand, professor of medical informatics and clinical epidemiology at Oregon Health and Science University, had examined the recently updated WPATH Standards of Care (SOC8) and noted that WPATH’s recommendations lacked a grading system to indicate the quality of the evidence—one of several deficiencies. Helfand noted that a trustworthy guideline would be transparent about all commissioned systematic reviews: how many were done and what the results were, and remarked that neither was made clear in the WPATH guidelines. Helfand also noted several instances in which the strength of evidence presented to justify a recommendation was “at odds with what their own systematic reviewers found.”
The BMJ article went on to say:
Despite this, WPATH recommends that young people have access to treatments after comprehensive assessment, stating that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents.” And more globally, WPATH asserts, “There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures,” procedures that “are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria.”
The WPATH systematic review did not provide evidence to support their assertions of safety and efficacy, yet that did not stop WPATH making strong recommendations in its SOC8 guidelines in favour of medical hormonal and surgical intervention for children and adults with gender related issues.
These weaknesses in the WPATH approach to evidence and the rigour of its guideline development had been identified even earlier in a paper published in the BMJ2 in 2021 which found that WPATH SOC7 guidelines were based on lower-quality primary research, the opinions of experts and lacked grading of evidence. The authors concluded that WPATH SOC7 cannot be considered ‘gold standard’.
WPATH and the World Health Organisation
Even before the recent revelations about research suppression CAN-SG was very concerned that WPATH members had a prominent role in the development of WHO transgender guidelines and along with other organisations wrote to WHO about our concerns. As a result WHO clarified that the new guidelines would only cover adults, not children, extended the consultation period and recently announced additional members of the Guideline Development Group (GDG) in an attempt to widen the representativeness of the group. However most of the additional members work in affirmative gender clinics and there is no-one that brings perspectives that are potentially critical of the affirmative approach, such as those of detransitioners.
In light of this further highly incriminating evidence about WPATH’s disregard for and suppression of evidence about transgender health care, which undermines the credibility of WPATH as an organisation, CAN-SG has written again to the WHO to say that in our view the alliance between WHO and WPATH is inappropriate and creates significant reputational risk for WHO.
Conclusion
The latest revelations about WPATH, on top of everything else that has been revealed about its inadequacies in recent years, must surely mean that now is the time for all national and international health providers to ditch WPATH as a source of influence and advice. Organisations that continue to rely on WPATH guidelines risk harming their patients and clients through promoting poorly evidenced treatments that carry significant risk, and are making themselves vulnerable to legal action by people who believe they were harmed by those treatments.
References
1Gender dysphoria in young people is rising—and so is professional disagreement. BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p382 (Published 23 February 2023) Cite this as: BMJ 2023;380:p382
2Dahlen S, Connolly D, Arif I, et al International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment BMJ Open 2021;11:e048943. doi: 10.1136/bmjopen-2021-048943