Open letter in response to WPATH SOC v8

Dear WPATH, 

Genspect is an international alliance of parent and professional groups whose aim is to advocate for parents of gender-questioning children and young people. We wish to thank you for your work on SOC V8 and providing an open period to review and comment on this important document. 

In particular, we thank you for the inclusion of a new chapter focused on the needs of adolescents, as this recognizes that the guidance developed for adults cannot simply be extrapolated to younger people who are going through unique developmental phases, not the least of which is the physical developmental process of puberty. It is well-documented and understood in medical practice that physical, emotional, and cognitive maturity progresses through late adolescence until at least age 25. We urge you to extend the adolescent guidance to include those individuals. 

It is also important to keep in mind the end-users of your document and their need for clarity in order to better understand the implications of your guidelines and how to apply them in individual cases. We have particular concerns that your terminology lacks clear definition. The only way for clinicians and people coming at this topic from various backgrounds and disciplines to be able to properly interpret your guidance is with effective operationalization of terms. The failure to provide such clarity will lead to inconsistent and potentially detrimental treatment protocols. For example, your singular focus on often irreversible medicalization as the treatment pathway to address a young person’s “gender-related needs” while you also recognize that gender diversity should no longer be viewed as “rare” seems to work against your stated goal to develop appropriate eligibility criteria for children and adolescents seeking help from medical professionals in whom they place a great deal of trust. 

Indeed, the document lacks a clinical lens, which is exacerbated by inconsistent terminology usage that we believe renders it unusable. It compels its reader to approach WPATH guidance with a particular, well-established metaphysical framework. The Terminology Chapter claims that “Sex, gender, gender identity, and gender expression are used in the English language as descriptors that can apply to all people – those who are transgender and gender diverse (TGD), and those who are not.”  However, not all people believe they have a gender identity. Please be more inclusive and recognize that some people do and others do not have an inner sense of gender identity. Unless you can demonstrate studies that prove that every human has a gender identity, this must be presented accurately as a theory. 

For parents, the reality of a child seeking invasive and irreversible medical interventions to align their physical bodies with a poorly understood and culturally dependent notion of “gender” is alarming and requires considerable reflection and careful decision making. What consideration is being given to the clinical condition that is being treated? Why, as parents acting in the best interests of our children, should we be asked to take a leap of faith that this poorly understood model of care is appropriate when the lives of our most precious loved ones are hanging in the balance? A model of care that is designed to render their “gender-related needs” entirely dependent on lifelong medical treatments. 

We are particularly disappointed that you say a systematic review of the evidence was not possible. As an international organization, certainly you are well aware of the recent systematic evidence reviews conducted in Finland and the UK and that Sweden is now undertaking. These national governments have applied very rigorous reviews. 

The key issue isn’t that a systematic review isn’t possible – it’s that the evidence itself was found to be very poor quality. This should concern every clinician, patient and parent. These evidence reviews have led to more caution being applied in the treatment of children and adolescents in certain jurisdictions. This is because reasonable people do not want to see children harmed by a train driven by pro-medical transition activists that is clearly reeling off the tracks. 

In fact, the most glaring omission in your documents is the role of supportive psychotherapeutic approaches in managing distress. An unbiased examination of valid psychotherapeutic approaches is necessary, and primary care clinicians should be guided to these approaches as a first line of treatment, especially for youth. Page 8 of the SOC V7 states, “Often with the help of psychotherapy, some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body.”  What is utterly lacking in your updated version is the endorsement and guidance for mental health clinicians to facilitate this exploration and integration.  Further, guidance is sorely needed to help clinicians determine when non-invasive techniques such as gender exploratory therapy versus invasive options (such as puberty blockers or cross-sex hormones) should be recommended. 

Detransitioners have cited gender exploratory therapy as a model of care that would have helped them ameliorate distress and disentangle their confusion about gender along with other personal issues. Clinicians and families also need guidance to treat and support detransitioners. Indeed, a chapter on detransitioners is clearly warranted as this growing cohort has unmet physical and mental health needs.

Parents are key stakeholders who hope that consumers of this document will act in the best long-term interests of their children given the life-changing medical care decisions being made. The responsibility of WPATH, now that you’ve declared gender diversity (the condition for which this document is intended?) is not “rare,” is to ensure that the practice of medicine is not being co-opted by bias or special interests that will adversely and permanently impact the health and well-being of young people and our society at large. 

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