WPATH, the World Professional Association for Transgender Health, is a non-profit organization that creates and maintains Standards of Care that help dictate how health providers, institutions, and insurance plans all over the world provide health care to transgender and gender diverse individuals. It is also used by trans people, their support systems, and other institutions to better understand how to best support trans individuals.
From time to time, WPATH revises its Standards of Care and requests input from interested parties. WPATH is currently accepting such feedback on the latest proposed changes at https://www.wpath.org/soc8 with a deadline of January 16th, 2022 at 11:59pm GMT. There are many unjust, regressive, and harmful proposed elements that need to be pushed back against, and this is the chance to do that.
In order to submit input, one needs to provide the following details:
- First and last name
- Email address
- An organizational, university, or institution affiliation
- The relationship to trans healthcare
We encourage those who can to read through the revised Standards of Care documents and submit feedback to improve them. We also encourage everyone to spread word of this to others, whether they are able to submit feedback themselves or not.
NOTE: Do not misrepresent yourself as part of an org you are not truly a part of – that would likely invalidate your feedback.
Because of the high proportion of asexual and aromantic people who also identify as transgender or gender diverse, because aromantic and asexual people’s health concerns are often overlooked, and because TAAAP is composed of many trans and nonbinary individuals, we submitted this feedback to WPATH. Each section has a link to the full text of the chapter, followed by our comments on the specific statements and the overall chapter.
TAAAP Comments on WPATH Standards of Care:
Reproductive Health Chapter
Statement 2 comment: The explication states that “Sterilization is a violation of human rights” without specifying forced/non-consensual sterilization or sterilization of people who are interested in fertility preservation. Elective sterilization is a valid contraceptive option for people who wish it, and that should not be lumped in with human rights violations.
Chapter overall comment: This chapter fails to give consideration to the unfortunate reality that many health providers deny treatment that impacts the ability to carry children solely due to paternalism, sexism, and amatonormativity, especially to young adult patients. Health providers should be advised to not insist that everyone wants or will have children or that patients will change their mind in the future and to not insist on exploring fertility preservation if the patient states they do not want to have children. (For example, the Nonbinary chapter, statement 4 explication states: “A decision by a nonbinary or gender diverse person that fertility preservation or counseling is not desired or needed should not be used as a basis for denying or delaying access to hormone treatment.”) Additionally, for some individuals, sterilization may be a desired part of gender-affirming care.
Sexual Health Chapter
Statement 2 comment: This is not inclusive of nonpartnering people who are sexually active. Health providers should be able to provide guidance to the individual patient on how to approach and have conversations to “set realistic expectations, disseminate helpful and accurate information, and facilitate gender-affirming positive communication related to sexual health,” not just facilitate such conversations for a couple.
Intersex Chapter
Statement 7 comment: The explication affirms parental distress instead of the intersex patients themselves. It skirts around connecting the dots from describing parental distress to its impact on the child. Instead of saying that “This situation may affect parental care and long-term outcome of their child with physical intersexuality,” the message should be more like “Harmful or unsupportive parental attitudes are detrimental to care and long-term outcome of their child, making it especially important to connect intersex patients with professional and peer social support.”
Statement 9 comment: Parental distress should not be considered as a reason to perform binary sex assignment surgery. Unsupportive parental opinions should never be given precedence over the intersex child’s bodily autonomy and right to self-determination.
Adolescent Chapter
Statement 3 comment: This recommendation is not evidence-based, as there exists no evidence supporting it. Because the sample of the referenced study was exclusively limited to youth who had been required to undergo comprehensive assessments, there was no comparison to youth who had not been required to undergo the assessment, and the results cannot be extrapolated or generalised to support the assessment itself. The explication itself admits that the assessment has never been part of any study, so it is not possible to draw conclusions on its effect on outcomes. Moreover, the research evidence section disclosed that the study participants were also socially supported, and the clinic providing their care employed a multidisciplinary approach that included procuring support for gender dysphoria and emotional well-being. It is highly likely that the social and emotional support the patients had, not the requirement of a comprehensive assessment, were strong contributors to positive outcomes.
The American Medical Association Journal of Ethics (https://journalofethics.ama-assn.org/article/informed-consent-medical-care-transgender-and-gender-nonconforming-patients/2016-11) notes that “Distrust of mental health professionals within transgender communties has arisen in response to the requirement for a referral from a mental health professional prior to accessing medical care. This requirement can easily be experienced as a hoop that patients need to jump through. As such, it might compel patients to tell a mental health professional only what they feel the clinician needs to hear in order to ‘get the letter.’ Some patients might feel tempted to tell a stereotypical narrative of gender identity development and dysphoria … even if this narrative would not truly represent their authentic gender identity development, dysphoria, or understanding of their gender affirmation needs.” The Trans Health Survey research project report by Transgender Europe, Overdiagnosed but Underserved (https://tgeu.org/wp-content/uploads/2017/10/Overdiagnosed_Underserved-TransHealthSurvey.pdf) found that only 17.9% of healthcare users agreed that a mental health professional should decide if a person is ready for gender-affirming treatment.
Stonewall UK (https://www.stonewall.org.uk/system/files/stonewall_gra_response_-_final.pdf) contends that “Having to prove who you are to officials, whether in a medical or legal setting, is clearly out of step with the growing acceptance that the only person who can determine someone’s gender is the individual themselves. Trans people frequently describe submitting evidence as something that damages them and trans communities.” They also assert that “A reflection period, as with the submission of evidence, is in opposition to the principle of self-determination that must be at the centre of any new system of legal gender recognition. It perpetuates the myth that trans people don’t understand their identities or know what’s best for themselves.”
Additionally, there is a serious oversight in the recommendation that an assessment collaboratively include the adolescent’s caregiver(s), stating “Research shows that gender diverse youth do best when supported by their caregiver(s).” No guidance is offered for when an adolescent patient’s caregiver(s) is/are unsupportive of their identity. (For example, the explication of statement 11 states that “in some cases, parent(s)/caregiver(s) may be too rejecting of their adolescent child and their child’s gender needs to be part of the clinical evaluation process. In these situations, youth may require the engagement of larger systems of advocacy and support to move forward with necessary supports and care.”)
Statement 10 comment: This statement overtly advocates for both health providers and parents to act as paternalistic gatekeepers and deny adolescents their rights to bodily autonomy and self-determination. Telling health providers to “specifically pay attention to the developmental and psychological aspects of fertility preservation and decision-making competency for the individual adolescent. Adolescents may think they have made up their minds concerning their reproductive capacity, but … opinions regarding having biologically related children in the future might change over time” presumes adolescents to be incapable of making decisions about their own futures. It is also inappropriate to advise that “Health professionals should acknowledge that adolescents and parents may have different views around reproductive capacity and may therefore come to different decisions. Health professionals can be helpful in guiding this process.” Unsupportive parental opinions should never be given precedence over the adolescent’s bodily autonomy and right to self-determination.
This inappropriate guidance is in direct conflict with other standards. The ethics and human rights perspectives section of this chapter states that “it is an adolescent’s right to participate in their own decision-making process about their health and lives.” Statement 4 of the Nonbinary chapter explains that “A decision by a nonbinary or gender diverse person that fertility preservation or counselling is not desired or needed should not be used as a basis for denying or delaying access to hormone treatment.”
The recommendation is also not evidence-based. There exists no evidence supporting the presumption that adults will regret the decision to start gender-affirming treatment in adolescence due to the reproductive consequences. The research evidence section of this chapter clearly shows that regret and dissatisfaction rates in general following gender-affirming treatment decisions made in adolescence are extremely low. The only studies referenced as basis are of childhood cancer survivors. It is not appropriate to assume that loss of reproductive capacity due to fully informed choice to undergo medical gender transition would negatively impact a person comparably to loss of reproductive capacity caused by cancer treatment necessary to survival.
Statement 11 comment: The explication affirms parental doubts instead of the adolescent patients themselves. It is inappropriate to advise that “there are cases in which the parent(s)/caregiver(s)’ questions or concerns [regarding stability of gender and treatment needs over time] are particularly helpful in informing treatment decisions and plans. For example, parent/caregiver report may provide critical context in situations in which a young person experiences very recent and/or sudden self-awareness of gender diversity and a corresponding gender treatment request, or when there is concern for possible excessive peer and/or social media influence on a young person’s current self-gender concept. Contextualization of parent/caregiver report is also critical, as the report of a young person’s gender history as provided by parent(s)/caregiver(s) may or may not align with the young person’s self-report.” Unsupportive parental opinions should never be given precedence over the adolescent’s own identification, bodily autonomy, and right to self-determination.
This guidance is in direct conflict with other standards. In fact, the explication goes on to admit that “Gender histories may be unknown to parent(s)/caregiver(s) because gender may be an inward experience for youth, not known by others unless it is discussed.” More importantly, the ethics and human rights perspectives section of this chapter states that “it is an adolescent’s right to participate in their own decision-making process about their health and lives.”
Furthermore, this chapter’s section on gender identity development in adolescence states with regard to family questions about gender identity development both that “it is not possible to distinguish between those where gender identity may seem fixed from birth from those where gender identity development appears to be a developmental process” and that probing external impact on gender identity development is “clinically irrelevant.” Health providers should not be instructed to consider, let alone sanction, clinically irrelevant familial concerns when assessing patients. The same section also notes that supposedly spontaneous expression of gender diversity in adolescence is a positive result of increasing societal visibility and awareness of gender diversity (thereby enabling exploration and discovery for more people), and that the only attempt to “study” the “phenomenon” surveyed exclusively parents, and not the adolescents themselves, in communities that pathologise gender diversity. This “phenomenon” has moreover been debunked (Bauer et al. 2021 https://www.jpeds.com/article/S0022-34762101085-4/fulltext) and should not be given any consideration or platforming in the standards at all.
Statement 12 comment: This statement places disproportionate and undue burden on adolescents and promotes excessive gatekeeping by health providers. The extra barriers being recommended have been rightfully recognised as obstructive, and therefore not (or no longer) included, in adult assessments.
The requirement of 12A is worded to apply on the adolescent meeting diagnostic criteria for gender incongruence instead of on the health provider being competent in using the relevant diagnostic classification system. This is offensive for reasons already laid out in the explication. One of the comments received in the UK House of Commons Women and Equalities Committee Inquiry on Transgender Equality report, which included submissions from Stonewall; Press for Change; and trans individuals, panels, and advocacy groups (https://publications.parliament.uk/pa/cm201516/cmwomeq/390/390.pdf), noted that “The requirement to provide documentation regarding a diagnosis of gender dysphoria was particularly contentious. Mr Dunne noted that ‘the continued “pathologisation” of transgender identities [i.e. treating them as a disease or disorder] through the 2004 Act causes significant offence and distress.'” The parallel statement 1B of the Assessment chapter is clear that the requirement applies only where the applicable jurisdiction mandates a diagnosis in order to access care and that it applies on the competence of the health provider to use the relevant diagnostic classification system where mandated.
The requirement of 12B to have well-documented evidence of persistent gender incongruence of several years, compared to the adult assessment requirement only of well-documented persistent gender incongruence, is unreasonable. It is furthermore inconsistent with the acknowledgement in statement 2 of this same chapter that “For some adolescents, the pace to achieving consolidation of identity is fast, while for others it is slower” and “For some young people, gender identity development is a clear process that starts in early childhood, while for others pubertal changes contribute to one’s experience of themselves as a particular gender, and for many others a process may begin well after pubertal changes finish.”
The American Medical Association Journal of Ethics (https://journalofethics.ama-assn.org/article/informed-consent-medical-care-transgender-and-gender-nonconforming-patients/2016-11) notes that there is no scientific evidence of the benefit of requiring 12 months of lived experience in the gender identity the patient is affirming, and SOC8 has discontinued this stringent requirement in adult assessments. The Transgender Legal Defense & Education Fund (https://transhealthproject.org/documents/26/Medical_transition_without_social_transition.pdf) furthermore notes that “[A]s of 2009, ‘no scholarly journal article devoted to the [real-life test] or the [real-life experience] ha[d] ever been published,’ so the requirement had no scientific basis in the first place.“
The requirement of 12D promotes especially excessive gatekeeping of neurodivergent youth and denies their right to self-determination. It presumes neurodivergent people to be incapable of knowing themselves or making decisions about their own futures. Neurodivergent people are often more likely to not fit rigid cisnormative societal boxes or follow the corresponding expected social scripts, but it is ableist, invalidating, and disrespectful to medicalise a person’s gender identity by attributing it to or conflating it with their neurodivergence. Attributing gender diversity to neurodivergence or to a mental health concern, or vice versa, is pathologising and it prevents people from receiving the care they seek, both for gender affirmation and for mental health. It also hinders healthy gender identity exploration and development because the assumption that one’s neurodivergence overrides their ability to self-identify makes it more difficult for neurodivergent people to assert and feel secure in their gender identity.
The requirement of 12G to have an age minimum of 14 years and above for hormone treatment (estrogens and androgens) places disproportionately high barriers on youth who want to access hormonal medication for gender affirmation compared to the minimal friction faced by youth accessing it for other reasons. Hormone treatment is commonly offered for other reasons to people younger than 14 and without hurdles. For example, after onset of puberty in AFAB youth, hormonal combination (estrogen + progesterone) contraceptive pills are commonly recommended by dermatologists and pediatricians to treat acne, and both hormonal combination and progesterone-only contraceptive medications are commonly recommended by pediatricians to treat concerns such as dysmenorrhoea.
The requirement of 12H to have at least 12 months of GAHT prior to gender-affirming surgical procedures, or longer if required to achieve desired results, is in direct conflict with statement 3 of the Nonbinary chapter that “health professionals should consider gender affirming surgical interventions in the absence of hormonal treatment unless hormone therapy is required to achieve the desired surgical result.”