In September, the WPATH (World Professional Association for Transgender Healthcare) released its long-awaited eighth update to its standards of care (SOC) for transgender and gender diverse people, colloquially called the SOC8. WPATH is a globally recognized organization that has published internationally-accepted clinical guidelines for social, medical, and surgical gender-affirming care since 1979. The WPATH SOC are influential, often informing U.S. insurance policies for gender-affirming care and requirements for gender-affirming surgeries, thus enabling access to gender-affirming care. In their own words, “WPATH is committed to ensure that the highest standard of care is achieved and presented in our Standards of Care”. In practice, the SOC guidelines are, as defined by the World Health Organization, “recommendations intended to assist providers and recipients of health care and other stakeholders to make informed decisions”.
The Standards of Care were long overdue for an update; the WPATH SOC8 have been a work in progress for several years. The SOC7 came out in 2011, and transgender medicine is a rapidly evolving field; thus there have been changes in evidence, available resources, available interventions, and meaningful outcomes that necessitate an update by most standards. Contextually speaking, the WPATH SOC have a troubled history: editions before SOC7 were criticized by trans health care experts for creating unnecessary barriers to care, such as compulsory psychotherapy in the SOC5. Indeed, editions before SOC7, when WPATH was known as HBIGDA, or The Harry Benjamin International Gender Dysphoria Association, did not identify conversion therapy for trans people as unethical, used pathologizing language such as “gender-disturbed” and “disordered” gender identities, and were written predominantly by cisgender men, thus missing important aspects of care. Published in 1998, the HBIGDA SOC5 were developed in part by then-Chairman of the Standards of Care Committee, Dr. Stephen Levine, a vocal opponent of informed consent. He is a frequent expert witness for state corrections departments defending against trans inmates seeking gender-affirming care, for schools defending against trans athletes participating in school sports, and in defending exclusions of gender-affirming care from insurance policies, despite a Court concluding in a 2015 case that there was serious weakness in his report that undermine his credibility as an expert, including misrepresenting the SOC, fabricating an anecdote, and asserting that gender-affirming surgery is always elective and should not be made available to inmates. Despite Levine’s influence, and despite these now apparent flaws, the SOC5 were still a leap forward from the SOC4, published in 1990, which required mandatory genital exams on trans patients. In Harry Benjamin’s framework, to be eligible for care, “true transsexuals” had to exhibit hatred for their genitalia; those permitted gender-affirming surgeries were highly encouraged to assimilate into heterosexual identities and expected gender roles (including heterosexuality relative to their affirmed gender) and to avoid people with diverse gender identities or sexual orientations.
The general pattern with each iteration of the SOC has been to remove arbitrary assessment procedures and to iteratively divest from the idea that being trans is a form of mental illness. However, the legacy of that association is still felt in each version. Not only were prior editions developed by people demonstrably hostile to fundamental rights for trans youth and adults, but they also gatekept care for arbitrary and dehumanizing reasons. The history of SOC revisions has been steadily rolling back these arbitrary requirements and acknowledging that conversion therapies are harmful.
Though the SOC7 were another leap forward from prior editions, trans experts such as Dr. Kelley Winters, Ph.D., have kept a wish list for the SOC8 edition. Broadly speaking, those wishes center upon divorcing the SOC from dubious evidence and completing the removal of frameworks that construe simply being trans as a form of mental illness. One wish is to contextualize and rebut the “80% Desistance Myth,” an idea that arose from systematically flawed studies using outdated, unclear standards for who qualifies as “trans youth”, which holds that the majority of trans children will not identify as trans once they become adults. This conclusion has been staunchly discredited by scholarship and contradicted by recent research using modern standards but is not even fully supported by the authors of those studies. A related wish is for a more coherent and consistent working definition of gender dysphoria that does not construe the experience as simply being trans, removal of the requirement of a “12-month experience of living in an identity-congruent gender role”, and more transparent, less discriminatory standards for psychiatric practice with trans people. These wishes suggest that the ideal for the SOC8 would be to overcome the historical biases and pathologizing frameworks that have led past SOC versions to fall short in the eyes of trans scholars.
According to a WPATH-authored press release from Sept 15, 2022, the SOC8 result from a rigorous 5-year scientific effort by over 120 health care and academic professionals around the globe, building on decades of research, clinical experience, and extensive literature reviews. The SOC8 are the first version to use an evidence-based approach and are 260 pages of the most comprehensive set of guidelines yet on trans health (“trans” is used as a term here to encompass people whose gender identities do not align with the sex they were assumed at birth, including transgender, nonbinary, gender diverse, and gender nonconforming individuals). The latest edition is the first time trans adolescents and trans children have separate chapters devoted to their care. The SOC7 and the SOC6, published in 2001, contained one chapter dedicated to the assessment and treatment of both children and adolescents, as part of a 122-page and 22-page document, respectively.
Given that, in the United States, trans children and adolescents are today’s unwavering target of the conservative right, who couch their hateful rhetoric in pseudoscience and have for years mapped out an agenda to separate trans rights advocates from the greater LGBTQ movement to make trans people a weaker and more vulnerable target, it is unfortunately quite predictable that most of the media controversy around the SOC8 centers almost exclusively around the chapters on child and adolescent care. It is even more unfortunate that it centers around these chapters specifically for doing at least a little of what trans scholars have argued in favor of for decades.
Sowing seeds of doubt
Trans health care is not without precedent, and the model of gender-affirming care is well-established. Despite this, a favored tactic of the anti-trans faction is to present what we do as health care providers working with trans patients as experimental and dangerous which it is not. Medscape‘s article on the SOC8 quotes Aaron Kimberly, a trans male RN who is the founder and director of the gender-critical Gender Dysphoria Alliance, saying the SOC are “broad and vague,” and Erica Anderson, a clinical psychologist and trans woman, who is a proponent of gender exploratory therapy, calling those who do not observe the guidelines as “going rogue”. Taken together, these statements imply that not only do the standards of care fail to provide any consensus in trans health care but that even if they did, health care providers don’t follow them. The article neglects to mention that neither of the clinicians quoted is an unbiased, neutral party.
According to the Medscape article,
In North America, some clinics practice full “informed consent” with no assessment and prescriptions at the first visit, Kimberly said, whereas others do comprehensive assessments.
Kimberly is also a member of GenSpect, an anti-trans, gender-critical (GC) organization openly critical of the WPATH SOC8. Genspect shares a significant overlap with the Society for Evidence-Based Gender Medicine, or SEGM (more on them here), and both regularly peddle anti-trans pseudoscience. Julia Mason, Marcus Evans, Roberto D’Angelo, Sasha Ayad, Stella O’Malley, Lisa Marchiano, and Avi Ring are listed as Academic and Clinical Advisors for SEGM and on “Our Team” (Mason, O’Malley, Ring) or “Advisors” (Evans, D’Angelo, Ayad, Marchiano) for Genspect. Though SEGM has not released an official organizational position statement on the final publication of the SOC8, thecommentary SEGM made upon the draft release of the SOC8 earlier this year relied upon misleading frameworks and accusations of “bias” instead of the scientific consensus. This is in keeping with the organization’s track record.
Given his membership in Genspect, it is unsurprising that Kimberly opposed a ban on conversion therapy. He sets up a false dilemma: informed consent does not mean that there are no comprehensive assessments. The WPATH endorses informed consent and the affirmative approach. Anything else contradicts the WPATH principles of depsychopathologization, harm reduction, medical necessity, and informed consent protocols.
Kimberly is not alone in promoting misinformation about the content and construction of the SOC8. The anonymous authors behind the website “Beyond WPATH” goes so far as to claim, without citation, that the SOC8 release delegitimizes WPATH as an organization. They state that there is a lack of evidence for gender-affirming care, a claim that doesn’t hold to scrutiny. Beyond WPATH dismisses solid research in trans health as “low quality” research, a claim that reflects a fundamental lack of understanding of scientific studies; if we held all medical treatments to the same quality standards, we would have to outlaw cholesterol-lowering drugs. A numerical majority (7 out of 13) academic and clinical advisors to SEGM, specifically Mason, Ayad, Richard Byng, Marchiano, O’Malley, Michael Biggs, and Ring, signed Beyond WPATH’s declaration to…
…stand together in supporting alternatives to WPATH’s deeply flawed Standards of Care. We align with the most up-to-date science-based guidelines from those countries which have already evaluated and rejected the affirmative approach.
Anderson is a favorite source cited by “gender critical” pundits like Abigail Shrier and Jesse Singal, and a former board member of WPATH who resigned from the USPATH board of directors after a series of events sparked by reading Abigail Shrier’s Irreversible Damage. Anderson recently participated in a debate entitled “A Pro-Human Approach to Adolescent Gender Dysphoria” for FAIR, the Foundation Against Intolerance & Racism. FAIR’s Board of Advisors includes blackface defender Megyn Kelly, opponent of “cancel culture” and intersectionality and fan of the so-called Intellectual Dark Web Bari Weiss, anti-woke psychologist Steven Pinker, Abigail Shrier herself, opponent of Critical Race Theory Christopher Rufo, and anti-“woke” conservative Andrew Sullivan. In May 2022, FAIR filed an Amicus Curiae in support of Students for Fair Admissions, Inc, (SFFA), a nonprofit that challenged Harvard University’s admission practices. SFFA alleged discrimination against Asian American applicants, which some saw as an attempt to invalidate affirmative action. FAIR dispensed with all pretenses and contended in their testimony that ‘”race” is an artificial, arbitrary, and ill-defined concept’.
Though the WPATH SOC are guidelines, by and large, these guidelines are followed by gender-affirming clinics in the U.S. that operate on an informed consent model. Deviations from the SOC are exceptions, not the rule. They are often justified, such as a trans 14-year-old who has top surgery because they are significantly limited in life activities by the presence of their chest or a trans 17-year-old who has bottom surgery a week before they turn 18 years old. These rare cases can hardly be regarded as “going rogue,” and no one examining data could consider them common. In the vast dataset analyzed by Reuters News, only 56 such surgeries occurred that had insurance claims amongst over a hundred thousand adolescents diagnosed with gender dysphoria in the same three-year period.
In the very text of WPATH SOC8:
The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and for guiding treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria put forth in this document for gender-affirming interventions are clinical guidelines; individual health care professionals and programs may modify them in consultation with the TGD person. Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health care professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm-reduction strategies. These departures should be recognized as such, explained to the patient, and documented for quality patient care and legal protection. This documentation is also valuable for the accumulation of new data, which can be retrospectively examined to allow for health care—and the SOC—to evolve.
The type of misrepresentation Kimberly and Anderson present has serious consequences, serving to weaponize those who would villainize and outlaw trans health care. Medscape should take better care to source actual experts in the field.
Lately, health care centers have been targeted, physicians threatened with murder, scandals manufactured in the media, and patients left without resources for care that is difficult to access in the first place. Matt Walsh and Chaya Raichik, who runs the popular-with-right-wingers social media account Libs of Tiktok (and appears to fall into the Venn diagram of gender-critical anti-vaxxer, with a side of January 6 insurrection), have tweeted about several transgender clinics, causing websites to shut down and support groups to be canceled. Outrage based on false information has spread.
Removal of age limits
In the SOC8 update, the WPATH removed age recommendations. Some media claim this change removes safeguards to care, protects clinicians from being sued, and is “evidence of ‘ideology infecting medicine‘”. Lead author of the Child Chapter, Amy Tishelman, a psychologist in the Gender Management Service (GEMS) at Boston Children’s Hospital, has been personally targeted. Comments she made at the WPATH conference were taken out of context and misrepresented to the point that the WPATH released a statement condemning dangerous misinformation and reinforcing their prior stance:
We are appalled at the specter of clinics and individual healthcare providers being harassed and having to engage armed security personnel. WPATH and USPATH call on all Americans to reject this repulsive and threatening behavior.
Age restrictions for gender-affirming medical care for youth have always been arbitrary and unscientific. Puberty starts at different ages for different people and develops at varying paces. Despite what Elon Musk, who isn’t new to composing transphobic tweets, suggests, gender-affirming medical interventions are only indicated once a trans youth starts showing signs of puberty (Tanner Stage II development). The SOC8 are tailored to the development of the individual patient. Those of us in practice understand that every patient is different and requires individualized care. Treatment should be guided by Tanner stage, not age.
This principle applies to gender-affirming surgery as well. Though the WPATH SOC guidelines do not recommend considering gender-affirming surgical procedures with higher risks of complications in youth under 18 at this time, surgeons may rely on the maturity of a patient instead of chronological age to determine the readiness of a patient for a surgical procedure. Even then, records of minors having bottom surgery are rare, most of the minors are 17 years old, and procedures are not performed on young children. A 2019 review of the available research on gender-affirming surgery in trans youth noted that the reasons surgeons agreed to perform vaginoplasties on transfeminine minors included the patient having strong family support and the ability to recuperate in a safe environment, being able to “fully transition” before entering the workforce or college (which can be a safety issue), and future schedules that may impede post-operation outcomes.
Boston Children’s Hospital received a bomb threat after being accused on social media of giving children vaginoplasties. BCH has an age minimum of 17 to qualify for vaginoplasty. However, no one has had a vaginoplasty that young at BCH. Being 17 years old allows a patient to ask for one, not to get one, i.e., in BCH terminology, “qualify” means “you get put into a schedule”. A patient can schedule a vaginoplasty at 17 but cannot get one until the age of majority or 18. So no, Boston Children’s Hospital is not performing gender-affirming bottom surgeries on minors.
An article from The Daily Caller ostensibly defending the BCH backlash cited a study on stats for gender-affirming top surgery on minors. The cited study, which identified 204 gender-affirming surgeries at BCH from 1/2017 to 8/2020 on patients aged 15 to 35, also notes that 0% of the patients who had gender-affirming bottom surgery at BCH were minors. Rather than apologize, Genspect, who promoted the misinformation against BCH, tried to claim that adolescence lasts until age 25; therefore, BCH does indeed do surgery on adolescents.
It is revealing to contrast this reaction to a much more common clinical situation, specifically that cisgender girls under 18 can and do undergo breast augmentation and reduction without the conservative hand-wringing over “body mutilation” that top surgery incurs despite its noted benefits on gender congruence and chest dysphoria. Even cisgender patients experience physical and psychosocial well-being following reduction mammaplasty; studies largely conclude that the benefits of breast reduction surgery can provide adolescents outweigh the risks. Surgeries on cisgender minors are up to 24 times more common than surgeries on trans minors. It is estimated that, in 2020, 3,200 cisgender girls aged 13 to 19 received breast implants, and over 4,600 cisgender teenagers had breast reductions, while only 203 trans minors had top surgery. Reuter recently ran the numbers to identify how many youth have accessed gender-affirming medical and surgical care. They identified 256 gender-affirming top surgeries performed on trans youth aged 13-17 in 2020. In three years – from 2019 to 2021 – there were only 56 genital surgeries among patients ages 13 to 17 with a gender dysphoria diagnosis. To get a sense of the numbers, the analysis drew on public and private health insurance claims for about 330 million U.S. patients over five years from 2017 to 2021. This hardly means that clinicians are “going rogue.”
The moral panic about children having gender surgeries disregards the many obstacles trans people experience in access to surgical care, including socioeconomic barriers such as insurance access and out-of-pocket costs, barriers related to obtaining behavioral health letters in support of surgery, limited surgeon availability, and, for minors, the need for parental permission. Many insurance companies do not provide coverage for gender-affirming surgery on minors.
According to some media outlets, under SOC8, parents will no longer have input into their children’s care. The overreaction of the GC crowd is to the following statement:
We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.
The WPATH guidelines clarify that parents are an essential aspect of gender-affirming care:
Parent and family support of TGD youth is a primary predictor of youth well-being and is protective of the mental health of TGD youth (Gower, Rider, Coleman et al., 2018; Grossman et al., 2019; Lefevor et al., 2019; McConnell et al., 2015; Pariseau et al., 2019; Ryan, 2009; Ryan et al., 2010; Simons et al., 2013; Wilson et al., 2016). Therefore, including parent(s)/caregiver(s) in the assessment process to encourage and facilitate increased parental understanding and support of the adolescent may be one of the most helpful practices available.
Trans youth depend on their families for medical decision-making. Given that youth often need both parents’ permission to make legal or medical changes, this can create the need for a holistic approach that educates and supports all family members.
The SOC8 are vague about how harmful parental/guardian involvement is determined; in practice, courts often place a high burden on showing that a medical treatment that parents object to is necessary. The state is more likely to interfere if it is established that a child’s life is imminently endangered. The harm principle contends that state intervention is justified if parental refusal puts their child at significant risk of serious preventable harm; another long-used threshold, the “best interest standard”, argues that state intervention is warranted if a parent acts contrary to the child’s best interest. Genspect twists the SOC guidance by claiming that, in the SOC8:
There is a disregard parental authority by advising clinicians to prescribe hormone treatment to children without parental support. This creates triangulation, where the parent is deemed the persecutor, the child is the victim and the clinician is the apparent saviour. It is an unhealthy situation and causes unnecessary distress within families at an already very stressful time. WPATH’s advice will lead to alienation of parents as they advise clinicians to “challenge” parents who are considered unsupportive because of any concerns about early and aggressive medical procedures.
Such misunderstandings of policies that, in theory, allow trans youth to obtain gender-affirming care without the involvement of a parent or guardian are routine in U.S. conservative news. When a 2015 Oregon procedural ruling held that, because the age of medical consent in Oregon generally is 15, state Medicaid could, in theory, be used by a minor without the need for parental consent to cover gender-affirming surgeries, conservative news engaged in dramatic fearmongering – even though not one of them could identify even a single case of such a circumstance happening, and despite even trans activist groups cautioning against such a procedure unless it was necessary, as in the case of a child without parents involved in their lives at all.
Social influence…or not
Some see it as a victory that Lisa Littman, the creator of the term “rapid-onset gender dysphoria” (ROGD), is referenced in the new guidelines. However, this inclusion does not legitimize Littman’s pseudoscience nor give credence to social contagion theory. Littman is also a member of both the Gender Dysphoria Alliance and GenSpect. ROGD is not an actual medical diagnosis recognized by any major professional associations and has no good evidence to support its existence. The consensus of major health care associations, including the WPATH, is that ROGD should not be used in clinical and diagnostic applications. SOC8 may have referenced Littman due to the mass attention she has garnered in the mainstream and the transphobic fallout of her work.
The guidelines state:
Another phenomenon occurring in clinical practice is the increased number of adolescents seeking care who have not seemingly experienced, expressed (or experienced and expressed) gender diversity during their childhood years. One researcher attempted to study and describe a specific form of later-presenting gender diversity experience (Littman, 2018). However, the findings of the study must be considered within the context of significant methodological challenges, including 1) the study surveyed parents and not youth perspectives; and 2) recruitment included parents from community settings in which treatments for gender dysphoria are viewed with scepticism and are criticized. However, these findings have not been replicated.
There is a chasm of difference between Littman’s proposed and debunked ROGD hypothesis, in which teens “suddenly” experience gender dysphoria, and the cohort mentioned above of adolescents “who have not seemingly experienced, expressed (or experienced and expressed) gender diversity during their childhood years.” The latter cohort considers the multitude of factors related to coming out, the timing of identity disclosure, parental support and awareness, and the existence of identities beyond the binary.
Further, the guidelines state:
For a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider (Kornienko et al., 2016). However, caution must be taken to avoid assuming these phenomena occur prematurely in an individual adolescent while relying on information from datasets that may have been ascertained with potential sampling bias (Bauer et al., 2022; WPATH, 2018). It is important to consider the benefits that social connectedness may have for youth who are linked with supportive people (Tuzun et al., 2022) (see Statement 4). Given the emerging nature of knowledge regarding adolescent gender identity development, an individualized approach to clinical care is considered ethical and necessary. As is the case in all areas of medicine, each study has methodological limitations, and conclusions drawn from research cannot and should not be universally applied to all adolescents. This is also true when grappling with common parental questions regarding the stability versus instability of a particular young person’s gender identity development. While future research will help advance scientific understanding of gender identity development, there may be some gaps. Furthermore, given the ethics of self-determination in care, these gaps should not leave the TGD adolescent without important and necessary care.
In other words: sure, consider ‘susceptibility to social influence’ as a factor impacting gender identity; however, we must think about it critically. A possible “social contagion” factor should not in itself guide treatment or delay access to gender-affirming care. Those of us health care professionals in the field who are experienced and culturally competent in what we do complete comprehensive assessments for all of our patients; the idea of ROGD is not the wildcard the gender-critical crowd wishes it was. As the SOC clearly state: Littman’s “research” is flawed, nonreproducible, and should not be universally applied to guide adolescent care.
As with other statements in the document, this one should be worded more strongly: bias in Littman’s study was not “potential,” but deliberate. And though the guidelines source WPATH 2018, it would have been helpful to include their entire statement in the SOC8:
The term “Rapid Onset Gender Dysphoria (ROGD)” is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation. WPATH also urges restraint from the use of any term—whether or not formally recognized as a medical entity—to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options in accordance with the aforementioned standards of care and clinical guidelines.
Regardless of the intent for including Littman in the guidelines, WPATH’s bottom line is that the basis of care is still affirming.
A few pages later in the guidelines, Littman is cited to acknowledge the phenomenon of detransitioning. Littman’s most recent study, just like the original, skewed results by drawing from blogs openly hostile to transgender youth, the same blogs where Littman developed the concept of ROGD in the first place. Curiously, Littman was chosen to represent this phenomenon instead of other work, and criticisms of Littman were not explicitly cited. A note here on language: where “detransition(/ing/ers)” identifies those who desist from a binary and static trans identity and has been predominately used by the GC faction to push an anti-gender-affirming care agenda, “retransition” acknowledges that some people halt transition for a time, that genderfluid and nonbinary identities exist, and that there are many reasons for re/detransition. Re/detransition is rare and does not mean regret, yet, naturally, as the number of trans people accessing gender-affirming care rises due to better access to resources and health care, even if the proportion of re/detransition remains the same, there will be a higher number of re/detransitioners. Contrary to the GC rhetoric, gender-affirming care includes support for re/detransitioners. As expert in trans health and researcher Dr. Johanna Olson-Kennedy, MD, testified in a federal lawsuit against Florida’s anti-trans health care ruling:
The affirmative approach considers no gender identity outcome: transgender, cisgender, or otherwise, to be preferable. (Turban and Ehrensaft, 2018). It permits a child to explore gender development and self-definition within a safe setting. A fundamental concept of this approach is that gender diversity is not a mental illness. The gender-affirmative model is defined as a method of therapeutic care that includes allowing children to speak for themselves about their self-experienced gender identity and expressions and providing support for them to evolve into their authentic gender selves, no matter at what age. Under this model, a child’s self-report is embedded within a collaborative model with the child as subject and the collaborative team including the child, parents, and professionals.
What is absent from the SOC8 commentary on re/detransitioners is actual guidance or recommendations for care of this patient population, as those who have stopped hormones for various reasons found re/detransition mentally and physically challenging and often avoided health care providers due to stigma. Retransitions happen infrequently and should be facilitated in a gender-affirming framework, as smoothly as possible for youth.
Gender exploration, not gender exploratory therapy
The latest attempt at couching conversion therapy in a palatable language is called “gender exploratory therapy“. There is a difference between gender exploration and disaffirmation. Ongoing gender exploration, a natural and positive process for all youth, should be encouraged and should not be a barrier to accessing gender-affirming medical care. The SOC8 encourage healthy gender exploration while noting that attempts to force gender exploration onto a patient are ill-advised and unwelcome; not all gender-diverse youth want to explore their gender.
Cisgender children are not expected to undertake this exploration, and therefore attempts to force this with a gender diverse child, if not indicated or welcomed, can be experienced as pathologizing, intrusive and/or cisnormative (Ansara & Hegarty, 2012; Bartholomaeus et al., 2021; Oliphant et al., 2018).
Gender exploratory therapy means first-line “treatment” for trans youth with gender dysphoria is psychological and seeks to “avoid the risks of social and medical transition“. In 2017, Dr. Richard Green published a legal strategy to circumvent laws and health policies prohibiting gender-conversion psychotherapies by simply labeling such practices as “gender identity exploration or development”. To the opposition, the disapproval of pushing gender-diverse children into making sure they’re confident they’re not cisgender is equivalent to pushing children into being trans.
The SOC8 should have been firmer on their stance here. Conversion therapy increases psychological distress and suicide attempts and should be banned, plain and simple. Affirming interventions improve mental health, promote well-being, and mitigate anti-trans stigma. Additionally, it would have been helpful for the SOC8 to include a discussion of the dangers of disaffirming therapy, including gender exploratory therapy. Statement 7.5 condemns any efforts to discourage a child’s gender-diverse expressions or identity:
We recommend health care professionals conducting an assessment with gender diverse children access and integrate information from multiple sources as part of the assessment. A comprehensive assessment, when requested by a family and/or an HCP can be useful for developing intervention recommendations, as needed, to benefit the well-being of the child and other family members. Such an assessment can be beneficial in a variety of situations when a child and/or their family/guardians, in coordination with providers, feel some type of intervention would be helpful. Neither assessments nor interventions should ever be used as a means of covertly or overtly discouraging a child’s gender diverse expressions or identity.
Conclusion: progress, not perfection; improvement with room to grow
Those of us in the trans health field practice gender-affirming, informed consent care in the framework of science-based medicine, as bolstered by the WPATH SOC8. Are the WPATH SOC8 perfect? Far from it. Are they intended to be rigid, immovable, and followed without questions? That would be unscientific. The SOC8 are best practices meant to evolve as science evolves and new research develops and adapts to individual clinical situations.
Overall, the SOC8 guidelines are a step in the right direction: they endorse informed consent, gender-affirming care for gender incongruence (this is notable, as not every trans person experiences gender dysphoria), and dispense with arbitrary gatekeeping such as age-based guidelines. The SOC8 edition is at its most robust when it sets out why it has flexible guidelines for care and at its weakest when it tries to placate the GC crowd. The SOC8 attempted to throw several bones to the GC crowd-and the GC crowd still objected. This would be a win for them if they cared about the evidence. Of course, it’s not about evidence, so they act as though it’s a loss. What the GC crowd explicitly objects to in the SOC8 is that this latest edition doesn’t advance their efforts to gatekeep care. That is because, regardless of their claims otherwise, those opposed to trans care aim to vilify trans people, delegitimize trans medicine, and put a full stop to any provision of gender-affirming health care, not to improve gender-affirming care based on science.