Reactions to and Assessment of the SOC Chapter on Adolescents

Dear WPATH:

I have reviewed the chapter on Adolescents in the draft 8th Edition of the Standards of Care.

I have three main impressions of this chapter overall.

1.        First, I was struck by WPATH’s complete and utter lack of curiosity about the youth being served.  Do you ever wonder why so many kids with neurodevelopmental differences, ADHD, trauma, anorexia, and anxiety show up in the gender diverse population?  Isn’t it important to understand why?

Our city’s newspaper said that 40 percent of the kids at a local Psychiatric Residential Treatment Facility are gender diverse.  A staff member from the juvenile psychiatric ward of a local hospital told me there are now typically four trans-identified girls on his floor at any given time when it was rare to see a single transgender youth in the past. Gender diverse youth are also overrepresented among adoptees, runaways and in the child protection system.  Aren’t you interested in knowing why so many trans kids are showing up in these programs and systems? 

You seem to assume all these odd comorbidities and subpopulations within the trans population can be explained by trans kids having unsupportive parents.  Wouldn’t it be good to test that hypothesis rather than risk an incorrect assumption? 

You note the marked increase in the numbers of girls and adolescents presenting as transgender in recent years.  Shouldn’t you figure out why this increase occurred before you start treating them as though you know what you’re doing? 

Usually, health care providers are searching for the least risky and least invasive ways to treat a condition.  What research are you doing to find ways to treat youth’s discomfort that do not involve drugs and surgeries that compromise long-term health? Aren’t you at all curious to find better, less risky and less invasive ways to help kids?

I don’t see any real curiosity about the adolescents you are serving and how you might serve them better.  I mainly see efforts to justify medical treatments no matter what anomalies you notice in the population.

2.       Another thing that struck me about this chapter was the number of times you acknowledged how little you know.  A few examples from this chapter are listed below:

“…the number of studies is still low, with few outcome studies following youth into adulthood.”

“Limited studies are available on the specific risks and benefits of tucking in adults, and none in youth.”

“There is no formal research on how menstrual suppression may impact gender dysphoria.”

“Currently, there are only preliminary results of retrospective studies of transgender adults regarding decision that they made about the consequences of medical affirming treatment on reproductive capacity when they were young.”

“Little is known about how processes of adolescent identity consolidation…may impact a young person’s experience(s) of gender.”

“Although by clinical observation an increasing number of youth are coming to self-identify as gender diverse in later adolescence, nothing is known about how their gender trajectories compare to those of youth who have come to know their gender diversity earlier. This is a much-needed area of research.”

“There is however, limited data on the optimal timing of gender affirming interventions and long-term physical, psychological, and neurodevelopmental outcomes in youth.”

“The potential neurodevelopmental impact of extended pubertal suppression in gender diverse youth has been specifically identified as an area in need of continued study.”

“The potential decrease in bone mineral density as well as the clinical significance of any decrease needs continued study.”

“The potential negative psychosocial implications of not initiating puberty with peers may place additional stress on gender diverse youth, though this has not been explicitly studied.”

Yet, despite all of the poor quality, inconclusive, or missing data, you still feel comfortable medicalizing gender diverse adolescents. Why is this?

3.       The third thing that struck me about this chapter was the extremely low value you place on the physical body.  The body’s value seems to be limited to whether its appearance allows an individual to pass as their identified gender, even if the person is experiencing no distress. [i] If we are lucky, our bodies will carry us through 80 years of living and if we choose, allow us to reproduce. If we want to enjoy those 80 years, we would be wise to care for our bodies and limit drugs and surgeries that may have long-term impacts.  This perspective becomes clearer as we age.  Due to testosterone use, my child is already experiencing thinning skin on the vulva leading to pain and bleeding.  I fear vaginal atrophy followed by hysterectomy is ahead.  Hysterectomy leads to greater risk of strokes, bone loss, heart attacks, and urinary issues.  I also fear that someday, the few years my child got to look like a cool, young dude won’t seem worth the price.

I also have a few reactions to specific sections of the draft chapter on Adolescents, listed below:

• Paragraph 2, page 3 says, “…It is important to note 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.  However, probing the contribution of the environment on gender identity development is difficult and clinically irrelevant.” 

You provide no explanation of why the contribution of environment is clinically irrelevant. If a youth develops a transgender identity after binging on transition TikTok videos for a month, that seems like a highly relevant environmental factor to me.

• Paragraph 3, page 3 says “Dutch longitudinal clinical follow-up studies on adolescents with childhood gender dysphoria who received puberty suppression and/or gender affirming hormones after comprehensive assessment, demonstrated that no youth refrained from pursuing gender affirming surgery years later; these findings suggest that many adolescent who were assessed and determined emotionally mature enough to make irreversible treatment decisions, presented with stability of gender identity over time when the studies were conducted.”

In this quote, you are confusing correlation with causation.  There is a correlation between receiving puberty suppressing and/or cross sex hormones after comprehensive assessment and pursuing gender affirming surgery years later.  You seem to assume that the cause of this correlation is that comprehensive assessments were capable of discerning which kids were truly transgender. It seems unlikely that comprehensive assessment would be correct 100 percent of the time.

Another possible cause for this correlation is that taking puberty suppressing and/or cross sex hormones begins a cascade of interventions; that is one intervention makes it much more likely that the next will occur.  The hormones that trigger puberty initiate both sexual development and a huge amount of brain development.  It is possible that when you interfere with normal brain development through the administration of puberty suppressing and/or cross sex hormones, you may prohibit a child/adolescent from becoming comfortable in his or her own body.  In that case, the administration of these drugs is a form of conversion therapy. When watchful waiting was the dominant approach to treating gender diverse youth, most children’s gender dysphoria dissipated as they matured, [ii] possibly because of the  brain development that occurs during puberty.

You must acknowledge that you do not know why all kids who receive puberty suppressing and/or cross sex hormones go on to pursue surgery.  You need to find out if your initial interventions of comprehensive assessment followed by puberty suppressing and/or cross sex hormones are causing some adolescents to undergo unnecessary surgeries.  Now that you know about this correlation (i.e., all adolescents who receive puberty suppressing and/or cross sex hormones go on to pursue surgery), it would be highly unethical to pursue this course of treatment outside the context of research that is aimed at determining causation. 

• Page 5 discusses the available research evaluating gender affirmative treatments. I am truly appalled at the dearth of longitudinal follow-up given the seriousness and irreversibility of many gender affirming treatments.  The best available follow-up was seven years with the subjects being a mean age of 20.7 at follow-up.  Any other follow-up was two years or less.  None of research you cite gives the perspective of a mature adult on what they underwent as a child or teen.  There are many, many teens and young adults who think they do not want children at all and change their minds in their late 20s or 30s.  Loss of fertility is a major possible side effect of these treatments.  How can you possibly believe you have sufficient data to recommend these treatments, when there are almost no research subjects who can meaningfully reflect on the loss of fertility and balance that against any positive effects of treatment?  It would be hard to explain the emotional toll of infertility and infertility treatments to a teen or young adult.

• On page 5, you say “…no clinical cohort studies have reported on profiles of adolescents who regret or detransition after irreversible affirming treatment.”  Dr. Lisa Littman’s study of detransitioners was recently released; see: https://link.springer.com/content/pdf/10.1007/s10508-021-02163-w.pdf .  You need to include it in your review of the literature. 

• Statement 4, pages 12–14 discusses various ways to affirm a youth’s asserted gender identity.  These affirmation efforts are at odds with this quote from Statement 3, “There are many different gender identity trajectories that youth may experience.  For example, some youth will realize they are transgender or more broadly gender diverse and pursue medical interventions to align their bodies with their identity. For others, their gender exploration will help them better understand themselves, but will not result in affirming a gender different from what was assigned at birth or involve the use of medical interventions.” 

In Statement 3, you are acknowledging that we do not know what a youth’s discomfort with the youth’s natal sex will mean in terms of the youth’s ultimate gender identity.  Yet in Statement 4, you say a youth’s asserted identity should be affirmed. By affirming, you are telling the youth that you think their current asserted identity is the correct one rather than telling them that we don’t know what their discomfort means.  I would think it would make sense to come up with a set of universal, singular, personal pronouns that are not gendered/sexed for all clinicians to use with gender diverse youth.  This would allow clinicians to remain neutral about clients’ identities.  I know of one clinician who uses clients’ initials when talking to the client to remain neutral about affirming a specific identity through a name.  The message to clients during the assessment process is that we cannot make assumptions.  This is the time to explore and examine not to settle on an identity.

I am also concerned that through all the efforts to obtain an affirmative environment listed in Statement 4, clinicians are teaching kids the world has to perfectly adhere to their desires for gender affirmation for them to be happy. The healthiest transgender people I see are those who can acknowledge 1) they do have a sex; 2) it is different from their gender; and 3) while it is nice when people acknowledge their gender preferences, they are not destroyed when someone makes reference to their sex.  Health professionals are teaching our kids to be far too fragile.  It is easier to put on slippers than to carpet the whole world.   

My child never thought twice about using women’s toilets until the age of 16.  Then overnight, a facility with the women’s sign became an affront to my child.  There are people in this world who literally do not have a pot to piss in. There are people in this world who must still defecate in the open, and others still using outhouses.  We need to teach kids they can survive using a flushing, porcelain toilet in a private stall even if it has the wrong signage.  It will still get the job done and in a way that is far more physically comfortable compared to what much of the world’s population uses.  I am a woman and have used men’s facilities when the women’s room was unavailable or the line too long. Part of the resilience we have to teach all children, is that things won’t always go your way, and you really can roll with it. 

If someone happens to accurately clock a trans-youth’s sex, the person is simply observing reality. You don’t have to be afraid or angry when someone notices that.  I have watched my child grow more comfortable with messiness around people getting my child’s identity correct, and my child is in a much healthier place because of it.  Right now, we are teaching kids that they can have genders that are different from their sexes, but it is violence when other people recognize that fact. How is that helpful? Aren’t we teaching them to be ashamed of their very nature rather than to accept it?

We also have to balance the rights of transgender people against the rights of natal women.  Balancing transgender and natal women’s rights should not be an oppression competition.  We need to look for practical compromises and solutions that acknowledge both group’s needs/rights.

• Statement 6, page 15 advises health professionals to inform transgender adolescents about the health and safety implication of binding and tucking.  Humans have a long history developing practices that provide some perceived benefit while harming the body; e.g. foot binding, corsets, high heels, breast ironing, female genital mutilation. Eventually, the culture concludes, “That wasn’t a very good idea.”  Or as my child’s physical therapist said regarding the practice of binding, “If you push in things that are supposed to be pushing out, you’re going to have problems.”  What is different in the current moment, is that we have many health professionals encouraging the self-harm.  Our bodies should be just as respected as our psyches.

• Statement 10, pages 18-19 recommends that health professionals inform trans adolescents of the reproductive effects that various treatments entail including potential loss of fertility and options to preserve fertility.

The United Nations (U.N.) says that sterilizing someone without their consent is a human rights violation. For example, the U.N. has noted that intersex children commonly receive treatments that result in sterility, therefore the U.N. says, “…irreversible invasive medical interventions should be postponed until a child is sufficiently mature to make an informed decision.”

You acknowledge that the vast majority of children who take puberty blockers go on to cross sex hormones. Following puberty blockers with cross sex hormones carries a very high risk of sterility because the gonads never mature. Children do not have the maturity to give informed consent to sterilization at the age when they begin puberty blockers, yet a decision to use puberty blockers almost always puts them on a road to cross sex hormones resulting in sterility.

You should not be recommending treatments that put minors on the road to sterilization. It doesn’t matter how many discussions you have to inform them of the possible consequences. It doesn’t matter if you tell them of ways they can, in theory, preserve their fertility. It doesn’t matter if they have a fertility consultation. It doesn’t matter if you involve the parents. There is no way you can make up for the fact that developmentally, these youth are incapable of understanding the long-term consequences of these treatments. If you cannot understand that, I strongly question your grasp on child development. Do you really wish to be known as an organization that encourages clinicians to commit human rights violations against children?

According to the American College of Obstetricians and Gynecologists, “Approximately 14% of sterilized women request information about sterilization reversal,...Those aged 18–24 years at the time of sterilization are nearly four times more likely to seek reversal information and nearly eight times more likely to undergo a reversal procedure than women who are sterilized at 30 years or older.” It appears that even young adults have a hard time understanding the full ramifications of sterilization, much less minors.

Having experienced infertility treatments, I also doubt that any youth who tries to preserve fertility by harvesting and storing eggs or sperm can truly understand what conception and pregnancy through those means will be like. I also doubt they can truly comprehend the likelihood of success.

• Statement 12A, page 21 says, “Through this assessment process, health care providers may provide a classification when needed to get access to transgender - related care. However, a classification involving gender diversity connotes no pathology, in and of itself.” It also says, “…not all transgender and gender diverse people experience gender dysphoria and this should not preclude them from accessing medical affirming care.”

If there is no pathology and/or no dysphoria, why are providers prescribing drugs and doing surgeries?  In what other situation, do health insurers pay for drugs and surgeries when there is no pathology or even any distress?  If there is no pathology and/or dysphoria, then these are elective procedures, and the patient should pay out of pocket. You cannot have it both ways. By telling professionals how to “provide a classification,” so a client can get treatment when the client has no pathology or distress, you are encouraging health professionals to engage in fraud.

You say that “pathologizing transgender identities may be experienced as stigmatizing.” If a patient has a medical condition that requires medical treatment, it is the patient’s right to know and understand what that condition is. It is infantilizing to assume they must be shielded from knowing they have that condition. Again, if they have no medical condition, these are elective treatments.

• Statement 12B, page 23 says, “Although by clinical observation an increasing number of youth are coming to self-identify as gender diverse in later adolescence, nothing is known about how their gender trajectories compare to those of youth who have come to know their gender diversity earlier. This is a much-needed area of research.” 

You say this is a much-needed area of research, but yet you dismissed and vilified the one person who has shown some curiosity about the phenomenon, Dr Lisa Littman.  If you know nothing about their gender trajectories, treatment should be limited to youth enrolled in research studies until you do know something.  My child is one of these kids who self-identified in later adolescence and got on testosterone.  I do not appreciate, “The let’s try it and see what happens approach.”  I doubt you would either if it were your child.

• Page 23 says, “For example, the duration of persistent gender incongruence before initiating pubertal blockers may be much shorter than for initiating gender affirming hormones, given that pubertal suppression is intended to provide a young person with the time to explore their gender-related needs before deciding whether to progress to treatments that involve more irreversible elements.” 

You may “intend” puberty blockers to provide more time to explore gender-related needs, but the vast majority of kids who take puberty blockers go on to hormones.  In actual practice, puberty blockers begin a cascade of treatments rather than providing time to explore.  On page 28, of the SOC you even acknowledge concerns about puberty blockers leading to a decrease in bone mineral density.  Why are you claiming they are reversible when you really don’t know?

• Statement 12D page 24, says that health professionals should only recommend gender affirming medical or surgical treatments when “..mental health concerns (if any) that may interfere diagnostic clarity, capacity to consent and/or gender affirmative medical treatment have been addressed.”

I have talked to a number of parents whose children’s severe mental health needs were ignored in favor of affirming gender.  One child had an assessment that indicated a borderline personality disorder.  The clinician told the mother that the assessment had never been normed on the trans population. As a result, the clinician didn’t know how a trans youth would be expected to perform on the assessment, so the results could be dismissed. Your standards of care say mental health crises should be prioritized, but parents have no recourse when that does not happen. How are you as an organization going to provide some accountability when your standards of care are not followed? 

Girls are often diagnosed with autism later than boys are, and many are not diagnosed until they are adults.  Girls are better at camouflaging their ASD symptoms. Given the high numbers of transgender youth who have ASD, all girls requesting gender affirming treatments should be assessed for ASD.  If an assessment indicates ASD, it would allow clinicians to address this condition that can impact capacity to consent before recommending gender affirming medical treatments.

• On page 27, Statement 12.G. provides “… guidance on the age at which gender affirming interventions may be considered.”  The guidelines say that adolescents as young as 17 may be considered for a hysterectomy.

The National Women’s Health Network says, “It’s incredibly unlikely that a doctor will perform a hysterectomy on women ages 18-35 unless it is absolutely necessary for their well-being and no other options will suffice. This is because of possible physical and emotional risks. Complications during surgery can include infection, hemorrhaging, or bladder or bowel damage, but the risks of these are rather low. Long-term, it can increase the risk of stroke, bone loss, heart attacks, urinary issues, and early onset menopause in younger women. Possible complications that can impact a woman’s sex life includes vaginal dryness and a lack of interest in sex. It also prevents the possibility of a biological pregnancy, which can cause depression and psychological stress in some women.”

As mentioned in an earlier comment, according to the American College of Obstetricians and Gynecologists, “Approximately 14% of sterilized women request information about sterilization reversal,... Those aged 18–24 years at the time of sterilization are nearly four times more likely to seek reversal information and nearly eight times more likely to undergo a reversal procedure than women who are sterilized at 30 years or older.” It appears that even young adults have a hard time understanding the full ramifications of sterilization. 

You are destroying the fertility and toying with the long-term health of these adolescents.  Under any other circumstance doctors avoid performing hysterectomies on women under 35 for the reasons stated above.  No matter their gender, these adolescents’ physiology will respond to hysterectomy in the same way as any other female.  You really need to research ways to help these adolescents cope that do not take such a toll on their physical health and fertility. I cannot believe that is not a major thrust of your work. It’s time for WPATH to take my concerns, and those of others, about the misguided approach of affirmative care in adolescents, seriously and to initiate real change in what has become a non-scientific field, guised as real medicine.

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[i] https://www.transgendertrend.com/puberty-blockers/

[ii] http://www.jamescantor.org/uploads/6/2/9/3/62939641/cantor_fact-check_of_aap.pdf