WPATH and AusPATH alignment

The presenter referenced WPATH (World Professional Association for Transgender Health) as the authority in healthcare for the transgender diverse. From what we gather WPATH guidelines are widely used among Australian Gender Services.

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For example in December 2023, in the document entitled “Service evaluation of the Queensland Children’s Gender Service”, it is stated that the Queensland Children’s Gender Service (QCGS) is guided by the AusPATH-endorsed Australian Standards of Care for trans and gender diverse children and adolescents and the WPATH SOC 8 guidelines. We argue that neither of these guidelines are fit for purpose, as both pose risk to the safety and wellbeing of children and young people. This is because both organisations rely on poor quality research with methodological weaknesses, misrepresent or exaggerate research findings and conclusions, and are strongly influenced by activism in their guidelines and recommendations.

AusPATH (Australian Professional Association for Trans Health) and WPATH (World Professional Association for Transgender Health) are both organisations focused on transgender health, but they operate at different levels.
 

WPATH is an international, interdisciplinary professional organisation focused on transgender health. AusPATH, on the other hand, is a national organisation specific to Australia. It aligns with the international standards and guidelines set by WPATH, adapting them to the Australian context. Members of AusPATH often refer to WPATH's Standards of Care (SOC) in their practice, and there are professional overlaps with individuals being members of both organisations.

 

Overall, the values and goals of WPATH and AusPATH align, and the criticisms of one are typical of the other.

Guidelines

1) Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents,
2) World Professional Association for Transgender Health’s Standards of Care for the Health of Transgender and Gender Diverse People (8th edition) .

To aid the QCBS evaluation, I have provided a summary of the core criticisms of both organisations and request the QCGS instead use professional organisations that promote ethical evidence-based care.
 

1. WPATH (World Professional Association for Transgender Health)

WPATH is referenced as the authority in healthcare for trans and gender diverse people. WPATH is a voluntary organisation and sees itself as not merely a scientific organisation but an advocacy organisation (p.18)[i] for gender affirmative care. It has members of the medical profession and has trans individuals who are not licensed professionals who attend the organisation’s biennial meetings, who have influenced outcomes. Thirty one percent of the organisations that contributed to the SOC8 were trans advocacy organisations[ii].  This blurring of boundaries between medical and university centres on the one hand and advocacy agencies on the other has led to significantly different approaches towards clinical standards and research governance. Hence WPATH might be best characterised, not as a professional association, but as an activist organisation where an activist agenda is evident.
 

WPATH has been severely criticised for its most recent Standards of Care (version 8). WPATH members contributed recommendations to the Endocrine Society’s Clinical Practice Guidelines in 2017 which were based on low or very low quality of evidence[iii].

WPATH Standards of Care version 8 Controversy
Even though WPATH has named their treatment guidelines 'Standards of Care', also known as 'SOC', a recent court case[iv] revealed that WPATH considers these guidelines to be treatment recommendations rather than a definitive 'standard of care."
 

Ultimately, only the courts can determine whether clinicians who provide “gender-affirming” interventions can successfully invoke the standard of care defence in lawsuits alleging harm. Advocates may argue that many medical organisations currently embrace 'gender affirmation', following WPATH's treatment recommendations.

However, this argument may not hold up due to two key factors: the evidence base for 'gender-affirming' interventions[v], and the WPATH guidelines[vi] themselves, are recognised to be of very low quality. Additionally, a growing number of healthcare systems in the Western world have recently diverged[vii] from WPATH recommendations, sharply limiting paediatric gender transitions except in exceptional cases.

The latest Standards of Care have been deemed unreliable and unethical by a group of organisations, physicians, research scientists, mental health professionals, and other signatories to an online Declaration[viii] that supports alternatives to the WPATH Standards.

These health professionals encourage the use of up-to-date, science-based guidelines that minimise the risk of harm and respect the limitations of our current scientific evidence base. The Declaration aims to highlight concerns regarding the WPATH Standards of Care and to encourage healthcare professionals to utilise alternative resources that are available.

 

The signatories maintain that the World Professional Association for Transgender Health (WPATH) has lost its standing as the leading authority on healthcare for gender-questioning youth with the release of its Standards of Care, 8th Edition. The following factors contribute to its loss of authority and trustworthiness:
 

1. Persistence in Promoting Affirmative Care Model Despite Growing Scientific Scepticism:
   The Standards continue to endorse the affirmative care model, involving medical treatments for trans-identified youth. This approach is increasingly questioned, causing countries like Sweden, Finland, France, and the United Kingdom[ix] to abandon the affirmative care model.
    

2. Methodological Concerns: The WPATH's SOC for adolescents seeking hormones primarily relies on a single Dutch study, criticised for: biased methodology, limited follow-up, inability to distinguish hormonal interventions from psychotherapy effects, selection bias, and lack of replication in other studies. This compromises the guidelines' credibility. (The Myth of “Reliable Research”[x]).
    

3. “First do no harm”: Other countries now prioritise psychosocial support as the primary treatment, delaying drugs and surgery until the age of majority. In contrast, WPATH supports early medicalisation despite the lack of substantial supporting studies. (Suing over Medical Transition: The Case against WPATH[xi]).
   Please examine the long term harms of medicalisation of minors: here[xii].
    

4. Lack of Focus on Psychotherapy Assessments: Critics argue that although WPATH's SOC8 acknowledges the importance of psychotherapy assessments, it fails to sufficiently emphasise or detail these assessments. These are crucial considering the multiple causes and potential paths to resolution of gender incongruence in youth (SOC 8 lack of methodological rigor[xiii] ).
    

5. Reluctance to Conduct Randomised Controlled Trials: WPATH has been criticised for its reluctance to conduct randomised controlled trials in transgender healthcare, preferring observational cohort studies. Critics argue that this approach contributes to a lack of robust evidence supporting the guidelines. (Reference link xi). 
    

6. Child-Safeguarding: WPATH has been criticised for failing to meet basic child-safeguarding norms by removing nearly all lower age limits for medical and surgical interventions in a correction issued after the Standards' release.
    

7. Concerns Over Medical Ethics: WPATH's stance on medical ethics, focusing on achieving gender alignment rather than considering treatment risks and benefits, has raised ethical concerns. This is particularly troubling for irreversible treatments for minors. Notably, WPATH eliminated a chapter on ethics that appeared in earlier drafts. (WPATH explained[xiv])
    

8. Fetishism: Controversially, WPATH included ‘Eunuch[xv]’ without providing supporting evidence, as a new gender identity in its guidelines and linked to an external site[xvi] featuring graphic and sexual fantasy stories, including the castration of adolescent males.
    

9. Influence of Activism and Conflicts of Interest: Critics view WPATH as a blend of a professional and activist group, with significant involvement of activists. This has led to concerns about the influence of transgender activists and organisations on its practices. (Reference link ii: )
   
   The Standards of Care were developed by self-selected experts, raising questions about the rigour of their evidence examination and biases due to personal stakes in medical interventions. Concerns extend to potential conflicts of interest, including committee members serving on multiple guideline committees and the possible influence of pharmaceutical companies invested in the gender affirmation model of care (Canadian Gender Report[xvii]). 
   
   There is also a worry that some contributors to the WPATH Standards of Care may be more influenced by political activism than by their expertise as healthcare professionals, academics, or guideline specialists. For example, Susie Green from the UK charity Mermaids, who does not have a clinical background, was involved in writing WPATH's chapter on paediatric gender dysphoria. Additionally, some senior healthcare professionals who are WPATH members have reportedly raised concerns about the impact of activism on transgender healthcare practices (Shrier, 2021[xviii]).
    

10. Standards fail Detransitioners: WPATH's definition of 'detransition' is criticised for fundamentally mischaracterising the experience, disregarding the traumatic experiences of those harmed by gender-related medical interventions who return to living as their biological sex. The Standards offer no guidance for supporting individuals coping with the grief and pain of detransition. (Detransitioners[xix] , Detransition Research[xx] , Beyond Trans[xxi])
     

11. Lack of Systematic Review and Evidence: Despite claims of being evidence-based, the Standards of Care have been criticised for not acknowledging that independent systematic reviews ix rate the evidence for gender-affirming treatments in youth as very low quality, subject to confounding and bias, making conclusions uncertain. Critics also note WPATH's failure to perform a systematic review for its recommendations, often issuing statements without supporting evidence. For example, there has been no controlled clinical trial to evaluate the safety or efficacy of feminising/masculinising hormone regimens. Moreover, the guidelines contain contradictory statements, for example, acknowledging the non-persistence of childhood gender dysphoria into adulthood, while still endorsing early puberty suppression (Canadian Gender Report xvii)).
     

Overall, WPATH faces criticisms for insufficient evidence, methodological weaknesses, ethical issues, and the influence of activism in its guidelines and recommendations. Consequently, many health professionals vii no longer regard WPATH as a reliable source of clinical guidance in transgender healthcare. They view WPATH and its Standards as outliers internationally, unresponsive to the growing scientific concern over experimental treatments on children. This may be reflected in the 60% drop in WPATH’s membership, from 4,119 in January 2023 to just 1,590 members by this January. Given these factors, I argue that the Gender services should remove WPATH as a reference group and their guidelines should be dismissed, as they are not fit for purpose.

 

2. AusPATH - Australian Professional Association for Trans Health:

Members of WPATH in Australia automatically become part of the Australian Professional Association for Transgender Health (AusPATH). AusPATH contextualises WPATH’s guidelines for the Australian context. Consequently, the criticisms of WPATH equally apply to AusPATH.

For instance, in July 2021, the Society for Evidence-Based Gender Medicine conducted a thorough and independent examination of the references in the 2018 Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents[i]. They revealed that AusPATH relies on poor-quality research, often fails to acknowledge methodological limitations in studies, and at times misrepresents or exaggerates research findings and conclusions. AusPATH has also been accused of mischaracterizing psychotherapy for gender dysphoria as potentially harmful, despite the Royal Australian and New Zealand College of Psychiatrists (RANZCP) asserting that psychotherapy is not conversion therapy. Further; ‘There is limited high quality evidence to inform the provision or the withholding of medical interventions for gender affirmation of children and adolescents’.
 

We ask you to examine the following:
SEGM Response to “AusPATH Public Statement on Gender Affirming Health Care, including for trans youth”[ii]
Prof Whitehall demolishes Telfer's claim that puberty blockers are reversible[iii]

A Litany of ABC Transgender Myths[iv]

 

Key points for Consideration
1. AusPATH, by following the gender affirmation model, posits that those who identify as transgender or gender diverse (TGD), or who present with gender dysphoria, inherently have a gender identity[v] distinct from their biological sex. This concept aligns with the Yogyakarta Principles, which define 'gender identity' as a deeply felt internal experience of gender, potentially incongruent with sex ‘assigned at birth’. This understanding underpins medical and surgical interventions for gender transitioning. However, this perspective is not universally accepted. Critics point out the lack of empirical evidence for an innate gender identity. Historically, gender dysphoria was treated as a mental health condition that often resolved with psychotherapy, without the need for medical or surgical intervention.

Yogyakarta Principles definition:
“Gender identity is understood to refer to each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms.”
 

(The definition is from the Yogyakarta Principles - promoted by ARC International, an organisation that was set up and funded by Stryker Medical Corporation which is a major supplier of gender transitioning products and receives ongoing funding from its foundation, ARCUS Foundation.)

 

2. Systematic reviews of evidence and testimonies from detransitioners suggest that the gender affirmation model is harmful and experimental. Critics argue it has an unreliable evidence base and can cause significant harm, sometimes even leading to death. There is no consensus in the medical community that Gender Affirming Care effectively reduces gender dysphoria.

 

3. Following systematic reviews, international medical boards are increasingly moving away from the Gender Affirming Care (GAC) model, which has been underpinned by low-quality evidence for the past decade. Organisations like WPATH, AusPATH, and others are now seen as potentially outdated and in conflict with emerging evidence.

Critics also highlight the influence of trans activists without medical or psychological expertise in these organisations, accusing them of introducing identity politics and pursuing financial gains through partnerships with the medical and pharmaceutical industries.
 

 

[i] 2018 Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents’. https://auspath.org.au/wp-content/uploads/2021/10/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents_v1-3.pdf/

[ii] ‘SEGM Response to “AusPATH Public Statement on Gender Affirming Health Care, including for trans youth”, https://ourduty.group/wp-content/uploads/2021/07/AusPATH-response-final-1.pdf

[iii] ‘Prof Whitehall demolishes Telfer's claim that puberty blockers are reversible’.

Updated: Sep 30, 2022, https://www.aww.org.au/post/prof-whitehall-demolishes-telfer-s-claim-that-puberty-blockers-are-reversible/

[iv] ‘A Litany of ABC Transgender Myths’, https://quadrant.org.au/magazine/2021/07-08/a-litany-of-abc-transgender-myths/

[v] ‘Yogyakarta Principles Gender Identity Definition’, https://www.screencast.com/t/1xM8qFKx/

 

[i] ‘Expert submission of Dr. Stephen b. Levine’, M.D. March 12, 2020, https://www.legis.state.pa.us/WU01/LI/TR/Transcripts/2020_0046_0001_TSTMNY.pdf

[ii] CTA. 2022. ‘“Get Them on Treatment!” WPATH and the Long Reach of US Trans Ideology into UK Healthcare’. Critical Therapy Antidote. 17 November 2022. https://criticaltherapyantidote.org/2022/11/17/get-them-on-treatment-wpath-and-the-long-reach-of-us-trans-ideology-into-uk-healthcare/.

[iii] ‘GAC Systematic Reviews | Section Five’. 2022. Active Watchful Waiting Inc. 2022. https://www.aww.org.au/gacsystematicreviews.’

[iv] ‘WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, PATHA Response to Bell v. Tavistock Judgment, Dec 2020, https://www.wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Statement%20Regarding%20Informed%20Consent%20Court%20Case_Dec%2016%202020.docx.pdf?_t=1608225376

[v] ‘New Systematic Reviews of Puberty Blockers and Cross-Sex Hormones’ Published by NICE, SEGM, March, 2021, https://segm.org/NICE_gender_medicine_systematic_review_finds_poor_quality_evidence

[vi] ‘International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment’, https://bmjopen.bmj.com/content/11/4/e048943

[vii] ‘One Year Since Finland Broke with WPATH "Standards of Care", SEGM, Jul 2021, https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors

[viii] ‘Beyond WPATH | WPATH Has Discredited Itself - Read and Sign the WPATH Declaration’. n.d. Accessed 7 January 2024. https://beyondwpath.org/.

[ix] ‘GAC Systematic Reviews | Section Five’. Active Watchful Waiting Inc. 2022. https://www.aww.org.au/gacsystematicreviews.’

[x] ‘The Myth of “Reliable Research” in Paediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed’, E. Abbruzzese, Stephen B. Levine &Julia W. Mason, Dec 2022, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2150346

[xi] ‘Suing Over Medical Transition: The Case Against Considering WPATH as a Competent, Reasonable Body of Expert Opinion’ By Peter Jenkins, https://genspect.org/suing-over-medical-transition-the-case-against-considering-wpath-as-a-competent-reasonable-body-of-expert-opinion/

[xii] ‘GAC Medical Damages | Section Three’, Active Watchful Waiting Inc. 2022, https://www.aww.org.au/gacmedicaldamages.’

[xiii] WPATH SOC8 Draft Guideline, SEGM critiques "Standards of Care" 8 for its lack of methodological rigor.  Jan 2022 https://segm.org/draft_SOC8_lacks_methodological_rigor.

[xiv] ‘WPATH Explained’, Genspect, Oct 2022, https://genspect.org/wpath-explained/

[xv] ‘Trans Health Authority Cites CASTRATION FETISH Site in Guidelines’. Reduxx (blog). Gluck, Genevieve. 2021.  Dec 2021. https://reduxx.info/trans-health-authority-cites-castration-fetish-site-in-guidelines/.’

[xvi] http://forums.eunuch.org/, castration example: https://web.archive.org/web/20050405003054/http://www.eunuch.org/Alpha/S/ea_230856sylvia__.htm

[xvii] ‘Bias, not evidence dominates WPATH transgender standard of care, Canadian Gender Report’, Oct 2019, https://genderreport.ca/bias-not-evidence-dominate-transgender-standard-of-care/

[xviii] ‘Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care’, Abigail Shrier, Oct 2021, https://bariweiss.substack.com/p/top-trans-doctors-blow-the-whistle/

[xix] ‘Detransitioners Provide a Warning’, Active Watchful Waiting, 2022, https://www.aww.org.au/detransitoners/

[xx] ‘Detransition Research, Active Watchful Waiting’, 2022, https://www.aww.org.au/detransition-research/’

[xxi] ‘Beyond Trans’, https://beyondtrans.org/

WPATH is a voluntary organisation and sees itself as not merely a scientific organisation but an advocacy organisation (p.18) of gender affirmative care.