Draft Guidance on Gender Dysphoria 'Misses Urgent Issues' – WebMD

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Dec. 14, 2021 – The release this week of new draft guidance for health care professionals treating people with gender dysphoria has raised fresh concerns that the influential group that wrote the proposed rules has been “captured by activists.”
Experts in adolescent and child psychology, as well as pedestrians, are shocked that the World Professional Association for Transgender Health’s Standards of Care 8 appear to show a radical leaning towards “gender-affirmation.” At the same time, critics say, the association misses out on some of the most urgent issues in the field of transgender medicine today.
The WPATH SOC 8 document is available for view and comment until midnight Thursday after which time revisions will be made and the final version published. Anyone may read the guidance and post comments.
Despite repeated attempts by WebMD to seek clarification on certain aspects of the guidance from members of the WPATH SOC 8 committee, requests were declined “until the guidance is finalized.”
According to the WPATH website, the SOC 8 aims to provide “clinical guidance for health professionals to assist transgender and gender diverse people with safe and effective pathways” to manage their gender dysphoria and potentially transition.
Such pathways may relate to primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services, and hormonal or surgical treatments, among others.
The associatoin adds that it was felt necessary to revise the existing guidelines, first published in 2012, because of the “globally unprecedented increase and visibility of transgender and gender-diverse people seeking support and gender-affirming medical treatment.”
Gender-affirming medical treatment means different things at different ages. In the case of kids with gender dysphoria who have not yet entered puberty, this might include prescribing so-called “puberty blockers” to delay natural puberty, a group of drugs that are licensed for use in early (precocious) puberty in children. Such agents have not been licensed for use in children with gender dysphoria, however, so any prescription of these agents for this use is “off-label.”
Following puberty blockers — or in cases where adolescents have already undergone natural puberty — the next step is to begin cross-sex hormones. So, for a girl (female) who wants to transition to male (FTM), that would be lifelong testosterone, and for a male who wants to be female (MTF), it involves lifelong estrogen. Again, use of such hormones in people with gender dysphoria is entirely off-label.
Just last month, two of America’s leading experts on transgender medicine, both psychologists — including one who is herself transgender — told WebMD they were concerned that the quality of the evaluations of youth with gender dysphoria are being stifled by trans activists who are worried that open discussions will further stigmatize trans individuals.
They subsequently wrote an op-ed on the topic entitled, “The mental health establishment is failing trans kids,” which was published in the Washington Post on Nov. 24, after many other mainstream media outlets rejected it.
One expert says the draft WPATH SOC 8 lacks balance and does not address certain issues while paying undue attention to others. The effect is to detract from real questions facing the field of transgender medicine, both in the United States and around the world.
Julia Mason, MD, is a pediatrician based in Gresham, OR, with a special interest in children and adolescents experiencing gender dysphoria.
“The SOC 8 shows us that WPATH remains captured by activists,” she says. 
Mason questions the integrity of the association based on what she has read in the draft SOC 8.
“We need a serious organization to take a sober look at the evidence and that is why we have established the Society for Evidence-Based Gender Medicine,” she says. “This is what we do — we are looking at all of the evidence.”
Mason is a clinical advisor to to the new group, an organization set-up to evaluate current interventions and evidence on gender dysphoria.
The pediatrician has particular concerns regarding the child and adolescent chapters in the draft SOC 8. The adolescent chapter says: “Guidelines are meant to provide a gold standard based on the available evidence at this moment of time.”
Mason disputes this statement. “This document should not be the new gold standard going forward, primarily because it is not evidence based,” she says.
Speaking to WebMD, Mason explained that WPATH officials say they used, a “consensus process” … designed for use with a panel of experts when evidence is lacking. “I would say they didn’t have a panel of experts. They largely had a panel of activists, with a few experts,” she says.
There is no mention, for example, of evidence reviews from England’s National Institute for Health and Care Excellence on puberty blockers and cross-sex hormones from earlier this year. These reviews determined that no studies have compared cross-sex hormones or puberty blockers with a control group and all follow-up periods for cross-sex hormones were relatively short.
This disappoints Mason: “These are significant; they are important documents.”
And much of the evidence quoted in the WPATH SOC 8 child and adolescent chapters comes from the well-known and often-quoted Dutch study of 2011, in which the children were much younger at the time of their gender dysphoria, compared with the many adolescents who make up the current surge in patients at gender clinics worldwide, she says.
Mason also stresses that the SOC 8 does not address the most urgent issues in transgender medicine today, mainly because it does not address rapid-onset gender dysphoria): “This is the dilemma of the 21st century,” Mason says. “It’s new.”
Rapid-onset gender dysphoria — a term first coined in 2018 by researcher Lisa Littman, MD, MPH,  — refers to the surge in adolescents expressing a desire to transition from their birth sex, after little or no apparent previous discomfort around their sex.
However, the SOC 8 does refer to aspects of adolescent development that might impact their decision-making processes around gender identity during teen years.
 “Adolescence is … often associated with increased risk-taking behaviors. Along with these notable changes…[and] individuation from parents…[there is] often a heightened focus on peer relationships, which can be both positive and detrimental,” the draft says.
The guidance goes on to point out that “it is critical to understand how all of these aspects of development may impact the decision-making for a given young person within their specific cultural context.” 
Mason also says there is little mention “about detransitioning in this SOC 8, and ‘gender dysphoria’ and ‘trans’ are terms that are not defined.” 
Likewise, there is no mention of desistance, she highlights, which is when individuals naturally resolve their dysphoria around their birth sex as they grow older.
The most recent published data seen  relates to a study from March 2021 that showed nearly 88% of boys who struggled with gender identity in childhood (approximate average age of 8 years and follow-up at average age of 20) chose not to transition. It reads:
“Most children with gender dysphoria will desist and lose their concept of themselves as being the opposite gender,” Mason says. “This is the safest path for a child — desistance.”
“Transition can turn a healthy young person into a lifelong medical patient and has significant health risks,” she says, stressing that transition has not been shown to decrease the probability of suicide, or attempts at suicide, despite myriad claims saying otherwise. 
“Before we were routinely transitioning kids at school, the vast majority of children grew out of their gender dysphoria. This history is not recognized at all in these SOC 8,” Mason says.
A new organization for concerned parents, Genspect, has also called out the so-called “suicide myth,” where many parents are told that if they don’t allow their daughter or son with gender dysphoria to medically transition, they risk their child committing suicide.
Ken Zucker, PhD, CPsych– an author of the study of boys who ultimately choose not to transition– is a psychologist and professor in the Department of Psychiatry at the University of Toronto. He says that terms ‘persistence’ and ‘desistance’ have been rejected by many WPATH members.
These two words, he says, are “particularly annoying to some of the gender-affirming clinicians because they don’t believe that desistance is,” he says.
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