The eighth update to the WPATH's standards of care for trans and gender diverse people was released in September of this year. Since 1979 WPATH has published internationally accepted clinical guidelines for social, medical, and surgical gender-affirming care. Insurance policies for gender-affirming care and requirements for gender-affirming surgeries are influenced by the WPATH SOC. WPATH is committed to ensure that the highest standard of care is achieved and presented in our standards of care The guidelines are meant to assist providers and recipients of health care and other stakeholders in making informed decisions.
The standards of care have been in need of an update for a long time. There have been changes in evidence, available resources, available interventions, and meaningful outcomes that necessitate an update by most standards, due to the rapid evolution of the field. The WPATH SOC were criticized by trans health care experts for creating unnecessary barriers to care in the past. The Harry Benjamin International Gender Dysphoria Association did not use pathologizing language when it was called WPATH. The Standards of Care Committee was chaired by Dr. Stephen Levine and he was an opponent of informed consent. He is an expert witness for the state corrections departments who defend against trans inmates seeking gender-affirming care, for schools who defend against trans athletes in school sports, and for insurers who exclude gender-affirming care from their policies. The SOC5 was still a leap forward from the SOC4 published in 1990 which required mandatory genital exams on trans patients. To be eligible for care, true transsexuals had to exhibit hatred for their genitalia; those allowed gender-affirming surgeries were highly encouraged to integrate into heterosexual identities.
The idea that being trans is a form of mental illness has been removed from the idea that being trans is a form of mental illness. The legacy of that association is still felt in the different versions. Prior editions were created by people who were hostile to fundamental rights for trans youth and adults. The history of revisions acknowledges that conversion therapies are harmful.
Dr. Kelley Winters has a wish list for the next edition. The wishes center on divorcing the SOC from dubious evidence and removing frameworks that say trans is a mental illness. One wish is to rebut the 80% Desistance Myth, an idea that came from flawed studies and holds that the majority of trans children will not identify as trans once they become adults. The conclusion is not supported by the authors of the studies used to back it up. There is a wish for a more consistent definition of gender dysphoria, removal of the requirement of a 12 month experience of living in an identity-congruent gender role, and more transparent, less discriminating standards for mental health. The ideal for the SOC8 would be to overcome historical biases and pathologizing frameworks that have led past versions to fall short.
According to a WPATH-authored press release from Sept 15, 2022, the SOC8 result is the culmination of a 5-year scientific effort by over 120 health care and academic professionals around the globe. 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. There are separate chapters for trans adolescents and trans children in the newest edition. There is a chapter dedicated to the assessment and treatment of both children and adolescents in the 2001 edition of the SOC7.
In the United States, trans children and adolescents are the target of the conservative right, who have for years mapped out an agenda to separate trans rights advocates from the greater LGBTQ movement. It's unfortunate that it's centered around these chapters specifically for doing a little of what trans scholars have argued in favor of for a long time.
The model of gender-affirming care is well-established. The tactic of the anti-trans group is to present what we do as health care providers working with trans patients as experimental and dangerous which is not true. According to Medscape, the founder and director of the gender-critical Gender Dysphoria Alliance and a clinical psychologist are both quoted in the article. It is implied that the standards of care fail to provide any consensus in trans health care, even if they did, because health care providers don't follow them. Neither of the clinicians quoted is an impartial party.
The article was published by Medscape.
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.
Genspect is an anti-trans gender critical organization that is critical of the WPATH. The Society for Evidence-Based Gender Medicine and Genspect are both anti-trans pseudoscience organizations. There was opposition to a ban on conversion therapy. He confuses informed consent with no comprehensive assessments. The affirmative approach is endorsed by the WPATH. The WPATH principles of depsychopathologization, harm reduction, medical necessity, and informed consent are not negotiable.
A former board member of WPATH resigned from the board after reading Irreversible Damage, a book that was cited as a favorite source by gender critical pundits. Anderson took part in a debate about a pro-human approach to adolescent gender Dysphoria. Megyn Kelly is an opponent of Critical Race Theory and is on the Board of Advisors. Students for Fair Admissions, Inc., a nonprofit that challenged Harvard University's admission practices, was supported by an Amicus Curiae. Asian American applicants were alleged to have been discriminated against by SFFA. Fair contended that race is an artificial, arbitrary, and ill-defined concept.
The guidelines of the WPATH SOC are followed by gender -affirming clinics in the U.S. The rule does not include deviations from the SOC. They are sometimes justified, such as a trans 14-year-old who has top surgery because they are 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. No one could consider these cases to be common. Over a hundred thousand adolescents were diagnosed with gender dysphoria in a three-year period, and only 56 of them had insurance for such surgeries.
There is a text in the very beginning of WPATH.
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.
Those who would villainize and outlaw trans health care will be weaponized by the misrepresentation presented by Kim and Anderson. Medscape needs to source experts in the field.
Health care centers have been targeted, physicians have been threatened with murder, and patients have been left without resources for care that is difficult to access. The two people who run the popular-with-right-wingers social media account "Limons of Tiktok" are Matt Walsh and Chaya Raichik. False information has caused outrage.
Age recommendations were removed in the update. The media claims that the change removes safeguards to care, protects clinicians from being sued, and is evidence of "ideology infecting medicine". Amy Tishelman, the lead author of the Child Chapter, has been personally targeted. The 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.
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.
There have always been age restrictions for medical care for youth. Puberty begins at different ages for different people. When a trans youth shows signs of puberty, gender-affirming medical interventions are only indicated. The individual patient is the focus of the SOC 8. Individualized care is required for every patient and those of us in practice know that. The treatment should be based on the stage.
This principle is applicable to gender-affirming surgery. Surgeons may use the maturity of a patient instead of chronological age to determine the readiness of a patient for a surgical procedure, even though the WPATH SOC guidelines do not recommend it. Most of the minor's are 17 years old, and the majority of the minor's have bottom surgery. According to a review of the available research on gender-affirming surgery in trans youth, the reasons surgeons agreed to perform vaginoplasties on trans females included the patient having strong family support and the ability to fully transition before entering.
The Boston Children's Hospital received a bomb threat after being accused of giving children vaginoplasties. BCH has an age requirement for vaginoplasty. No one at BCH has ever had a vaginoplasty. In BCH terminology, "qualify" means "you get put into a schedule" when a patient is 17 years old. A patient can have a vaginoplasty at 17 but can't have it until they're 18. Boston Children's Hospital doesn't perform gender-affirming bottom surgeries on children.
There is a study on the statistics for gender-affirming top surgery on minor girls. There were 204 gender-affirming surgeries at BCH over the course of a year, but only 204 of them were minor. Genspect, who promoted the misinformation against BCH, tried to claim that adolescence lasts until 25 years old, and that BCH does 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 modification" that top surgery incurs. Studies show that the benefits of breast reduction surgery can outweigh the risks for adolescents. Surgeries on cis gender are more common than surgeries on trans genders. In 2020 there are estimated to be 3,200 cis gender girls with breast implants and over 4,600 cis gender teenagers with breast reductions. The numbers were run to find out how many youth accessed gender-affirming care. There were hundreds of gender-affirming top surgeries performed on trans youth. There were only 56 genital surgeries for patients with a gender Dysphoria diagnosis in three years. To get a sense of the numbers, the analysis drew on public and private health insurance claims over a five-year period. It doesn't mean that clinicians are going rogue.
The moral panic about children having gender surgeries ignores the many obstacles trans people experience in access to surgical care, such as insurance access and out-of-pocket costs. Insurance companies don't cover gender-affirming surgery on minor.
Some media outlets claim that parents will no longer have input into their children's care under the new rules. The crowd overreacted to the 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.
Parents are an important part 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 rely on their families to make medical decisions. The need for aholistic approach can be created by the fact that youth need both parents' permission to make legal or medical changes.
In practice, courts place a high burden on showing that a medical treatment that parents object to is necessary in order to determine harmful parental involvement. If a child's life is in imminent danger, the state is more likely to intervene. State intervention is justified if parental refusal puts their child at significant risk of serious preventable harm and if a parent acts contrary to the child's best interests, according to the harm principle. In the SOC8 Genspect claims that.
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.
There are misunderstandings of policies that allow trans youth to get gender-affirming care without the involvement of a parent or guardian. The age of medical consent in Oregon is 15 years old, so state Medicaid can be used by a minor without the need for parental consent to cover gender-affirming surgeries.
The creator of the term "rapid-onset gender Dysphoria" is mentioned in the new guidelines. This inclusion doesn't give credence to social contagion theory. A member of both the Gender Dysphoria Alliance and Gen Spect. There is no good evidence to support the existence of ROGD. Major health care associations agree that ROGD shouldn't be used in diagnostic applications. Due to the attention she has gotten in the mainstream and the transphobia of her work, it is possible that SOC8 referred to her.
The guidelines tell you what to do.
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 the proposed and debunked ROGD hypothesis, in which teens suddenly experience gender dysphoria, and the cohort mentioned above of adolescents. The timing of identity disclosure, parental support and awareness are some of the factors considered by the latter cohort.
The guidelines state that further.
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.
It is possible to consider susceptibility to social influence as a factor affecting gender identity. Treatment and access to gender-affirming care shouldn't be affected by a possible social domino effect. The idea of ROGD is not what the gender-critical crowd would like it to be. The research is flawed and should not be used to guide adolescent care.
The statement that bias in the study was deliberate should be worded more strongly. It would have been beneficial 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.
The basis of care is still affirming regardless of whether or not the intent is to include Littman in the guidelines.
The phenomenon of detransitioning is acknowledged in the guidelines. The results of the most recent study were skewed because they were drawn from a blog that was hostile to the trans community. The phenomenon was represented by Littman instead of other work and criticisms of him were not mentioned. There is a note in the language where "detransition/ing/ers" is used by the GC to push an anti- gender-affirming care agenda. As the number of trans people accessing gender-affirming care increases due to better access to resources and health care, there will be a higher number of re/detransitions. Re/detransitioners are supported in gender-affirming care. The expert in trans health testified in the lawsuit.
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.
Those who have stopped hormones for various reasons found re/detransition mentally and physically challenging and often avoided health care providers due to stigma are missing from the commentary. In a gender-affirming framework, retransitions should be easy for youth.
There is a new attempt at conversion therapy in a palatable language. Gender exploration and disaffirmation are different things. It's not a barrier to access gender-affirming medical care if you're ongoing gender exploration. Not all gender-diverse youth want to explore their gender and that's why the SOC8 encourages healthy gender exploration.
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).
The aim of gender exploratory therapy is to avoid the risks of social and medical transition for trans youth. A legal strategy to circumvent laws and health policies prohibiting gender-conversion psychotherapies was published by Dr. Richard Green. The opposition believes that the disapproval of pushing gender-diverse children into making sure they are not cis gender is equivalent to pushing children into being trans.
The SOC8 should have been more assertive. Conversion therapy causes psychological distress and should be banned. Affirming interventions improves mental health. It would have been helpful for the SOC8 to discuss the dangers of disaffirming therapy. Any attempts to discourage a child's gender-diverse expressions or identity is condemnable.
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.
We in the trans health field practice gender-affirming, informed consent care in the framework of science based medicine. Is the WPATH SOC8 a good one? It's far from it. Is it possible that they are meant to be followed without questions? It wouldn't be scientific. As science changes and new research develops, the best practices of the SOC8 are updated.
The guidelines endorse informed consent, gender-affirming care for gender incongruence, and do away with age-based guidelines. When it explains why it has flexible guidelines for care and tries to appease the GC crowd, the SOC8 edition is at its strongest. The GC crowd objected to the attempt to throw bones. If they cared about the evidence, this would be a victory. It isn't about evidence, so they act as if it's a loss. The GC crowd objects to the latest edition of the SOC because it doesn't advance their efforts to gate keep care. Those opposed to trans care want to vilify trans people, delegitimize trans medicine, and put a stop to any provision of gender-affirming health care, not to improve gender-affirming care based on science.
All Rights Reserved © 2024
