Urgent Action to Protect Adolescents! Commentary Period is Now Open for Drafting the Standards of Care.
The World Professional Association for Transgender Health (WPATH) is currently working on their draft of the 8th version of the Standards of Care (WPATH SOC 8). This is a crucially important document in that it is used to establish guidelines for “best practices” in the mental and physical health care of gender variant individuals. The first SOC was published in 1979 and the seventh version (WPATH SOC 7) has been in use since 2011. A complete history can be found on Wikipedia.
WPATH has opened their draft of SOC 8 to public commentary for a two week period from December 2 to 16. Details can be found here. This will take you to the description of the feedback process and link you to the full text of each chapter draft and a survey inviting commentary. Today I completed this process for the chapter on adolescents. I read the full text up to and including the list of the 12 Statements. I will need to devote separate time to reading the details following the summary of the statements, as well as other chapters.
WPATH’s feedback form for this chapter invites feedback on the introduction through the 12th statement, so this is what I focused on. Screenshots of the document and my commentary are below. The text of my commentary has also been copied and pasted below the screenshots capturing the same. While this is redundant and lengthens the appearance of this article, it should make it easier for you to copy and paste anything you would like to use. Unfortunately, this article is too long for it to be distributed by email, so I hope my subscribers will access it another way.
Please feel free to use this to help you draft your own feedback, which can be submitted here until December 16.
"Barriers to care" in the first paragraph should be defined.
There is indeed a shortage of appropriate care for gender questioning teens. However, what "appropriate care" means is widely debated.
We need exponentially more mental health providers who are adequately trained in gender exploratory therapy as well as systems thinking and family therapy. Adolescents should be supported in identifying and understanding the myriad factors that could be playing a role in their dysphoria. Mental health providers should have the skills to help youth and families find the least invasive treatments. That is, what approaches might have the best outcomes for long term physical and mental health, while being the least invasive, and the least costly to consumers and taxpayers, without any medical fraud or waste of resources. Inadequate training and availability of mental health providers means that many healthcare professionals are enabling teenagers' natural tendency toward hasty impulsivity and supporting them in rushing to medicalize, which means they are going for the most invasive, risky, and expensive "treatments" that have lifelong consequences, when there is a 4 out of 5 chance that their dysphoria can desist, especially with appropriate mental health care. Why would we allow this rush when there are myriad unexplored reasons youth claim alternate gender identities, and appropriate exploratory care is likely to help them get comfortable in their own skin?
Paragraph 2: "These studies suggest that gender diversity in youth should no longer be considered rare."
Suggested correction:
“These studies indicate a need to better understand the nature and origins of the recent exponential rise in youth claiming transgender identities, and in the reversal in the sex ratios. [eg. That natal girls are now common than boys.] The concept of ‘gender diversity’ has been redefined over the past decades. Studies show that many gender diverse youth grow up to be gay (according to natal sex). Could it be possible that youth who define themselves with the current terminology to describe gender diversity might have, in previous decades, identified as gay or lesbian, tomboys, androgynous, effeminate men, and so forth?”
Paragraph 3 defines puberty blockers as "fully reversible." This has been thoroughly discredited by a myriad of sources. Youth who "pause" puberty miss out on important development of the nervous, endocrine, and skeletal systems, not to mention psychosocial factors. We now know that the vast majority of youth who start puberty blockers will go on to cross-sex hormones that they may not have gone on were it not for having blocked puberty. We know that those cross-sex hormones come with a host of other medical consequences impacting the cardiovascular system, metabolism, cancer prevalence, and more. We now know that Lupron has disastrous long term consequences for bone density. We also know that going through puberty is a necessary stage in brain development and that going through its ups and downs, however rocky, when adequately supported, is an important part of getting comfortable in one's biological sex, which is the least invasive treatment for dysphoria.
Methodology & Adolescence overview look good. Gender identity in adolescence looks good. These sections are missing use of the term Rapid Onset Gender Dysphoria & the research of Dr. Lisa Littman. All fairly good until we get to:
"However, probing the contribution of the environment on gender identity development is difficult and clinically irrelevant." WHAT? ALARM BELLS SOUNDING!
These are unscientific terms. What is "difficult" is completely subjective and there is no explanation given for why this should be objectively considered "difficult." Also, something being "difficult" does not mean it is not necessary or important, or that excluding it is warranted. In fact, some of the most necessary and important things in life are indeed quite difficult. So what's actually irrelevant here is not the role of the environment, but the perception that evaluating the environment is difficult. The fact of the matter is, there are tremendous difficulties that gender questioning youth are at risk of dealing with if we, the adult professionals who are responsible for their care, do not first do the difficult work that is our due diligence. Furthermore, dismissing this work as "difficult" fails to honor the many hard working individuals who are indeed doing this difficult work of understanding psychosocial and other environmental factors.
Deeming the role of environment "clinically irrelevant" is an obviously untrue statement that should sound alarm bells for any rational person. It's hard to contest this because the statement is so plainly false on its face. When has the role of the environment ever been clinically irrelevant in any significant medical or mental health issue?
And to say this of an issue pertaining to adolescents is especially absurd. It is well known that adolescents are one of the most vulnerable populations to environmental factors. They are highly influenced both by the home environment (as they still live with their families), and by their peer groups; and now, more than ever, by the online environment. Everyone knows this. It is absurd to dismiss it.
Page 5, paragraph 2 reports results of follow up after 2 years. I appreciate that this is framed with regard to lack of adequate long term data. However it's important to add how short 2 years is in the span of a lifetime, that "gender euphoria" is often an early honeymoon stage, and that the longer term health consequences of cross-sex hormones often take more than 2 years. For instance, vaginal atrophy is more commonly felt after 4 years.
Page 6, paragraph 3 states that ethical considerations were made, but there is a clear bias demonstrated by only framing ethical considerations in a way that favors rushing to medicalization, and not considering ethical considerations that honor the precautionary principle, eg. Chesterton's fence. The example given is phrased "allowing irreversible puberty to progress in adolescents who experience gender incongruence is not a neutral act given that it may have immediate and lifelong harmful effects for the transgender young person." There are several problems with this statement. Puberty has existed since the dawn of humanity, while the question of whether or not to "allow" it to progress has never existed before the 21st century. Here, nature unfolding as it always has been, without medical intervention, is framed as (1) an act, (2) not neutral, and (3) permanently harmful. I would argue that these are true of interfering in puberty, not of nature unfolding.
"In order to promote acceptance" is a statement indicating a clear bias in terms of the providers' worldview and sociopolitical orientation. "Promoting" any such agenda is not the job of a healthcare provider. Our job is to promote health, whether our particular domain in healthcare be physical or mental. Therefore, we will use our best expertise to promote whatever we believe is healthy according to a given situation. This may or may not include working with a family, school, or "other relevant setting," and it may or may not emphasize "acceptance of gender diverse expressions of behavior and identities of the adolescents."
Furthermore, lumping behavior and identity together is unwise. It suggests that a young person whose behavior tends to be non-normative gender wise - eg. a girl who prefers skateboarding over dancing - therefore must form an identity based on this. And in today's sociopolitical environment, the assumption is that "identity" isn't just a social persona or a sense of self, it's a particular set of labels and definitions that are all too easily associated with medicalization.
There is so much wrong with this statement.
First of all, this redefinition of conversion therapy is an insult to the LGB community. Identity is much more malleable and subject to social trends and definitions than sexual orientation, which is generally understood to be fairly immutable. There are no medical interventions necessary for being a sexual minority, nor are there any negative health consequences (aside from potential increase in HIV risk among gay men, which can be ameliorated through safe sex practices). In other words, there is no legitimate reason any therapist should seek to change the sexual orientation of their client.
Most adolescents have experienced sexual attraction to one or both sexes and are likely at least halfway through their process of discovering their natural sexual orientation, which, once discovered, will likely remain stable throughout their lifetime. In contrast, adolescents are in a developmental stage of experimenting with and exploring identity, personality, interests, mannerisms, styles of dress and grooming, and so on. This experimentation typically lasts until early adulthood, solidifying in the mid-twenties around the time the brain has fully matured. The process cannot be complete without various life experiences that form natural rites of passage. These more malleable aspects of identity are much more influenced by one's social and cultural environment, whereas sexual orientation tends to exist regardless of the social environment. The social environment can influence a sexual minority's comfort with their sexuality, openness about their sexual orientation with their community, and relationship options, among other things, but it cannot fundamentally alter their natural proclivity toward being hetero, homo, or bi sexual. This is why it is harmful for anyone to try to change another person's sexual orientation (or their own).
Gender identity is a completely different matter. A person's sex is not "assigned" at birth, it is identified based on biological reality. External sexual organs are clearly the most visible indicator of sex and are adequate for determining a baby's sex, but they also correlate with gametes, which are the ultimate biological determiner of whether an animal (human or otherwise) is male or female. A person's biological sex is the physical reality of the body they inhabit. Discomfort with any part of one's body is generally a cause or effect (or both) of mental distress. Any approach to mental health treatment that supports the individual in becoming more comfortable in their own skin and accepting of the physical reality of their life is bound to have better long term outcomes than an approach that encourages people to continue feeling unable to tolerate or accept physical reality and instead sells them the notion that invasive, costly, novel, and lifelong medical interventions are necessary in order for them to experience peace in life.
Therapists have a responsibility to help people accept and work within the constraints of reality, finding an internal locus of control that empowers a sense of being able to find inner peace regardless of external circumstances. Of course, sometimes our work does mean helping people to change their circumstances. We may help someone decide to leave an abusive marriage, pursue a career change, break an addiction, or take up a new health regime. However, the changes we support are always in the best interest of the patient's long term mental and physical health. If we are helping someone with a decision to change their body, the changes we support are in the interest of health, such as improving sleep hygiene, building an exercise habit, preparing nutritious meals, or taking medications or supplements recommended by the patient's physician. We do not encourage self-harm, self-endangerment, maladaptive behaviors, or erroneous thinking. We do not encourage patients to hate their bodies, starve, mutilate themselves, consume harmful substances, or remove healthy body parts. Whenever possible, we help our patients find healthier coping strategies to alleviate their distress.
Therefore, if someone comes to us hating their body, it is our job to help them identify coping strategies that are the least invasive, least risky, least costly, and most supportive of long term health. This has always been the case, since long before the current gender ideology. It is what we have always done to help treat eating disorders, self harm, and body dysmorphia. Doing our job appropriately in no way resembles the "conversion therapy" that has been used to attempt to change patients' sexual orientations, which has rightfully been banned as it is discriminatory, abusive, and detrimental to wellbeing.
Disagree. Menstruation is uncomfortable for almost all girls at first. Providers should help girls get comfortable with this natural process.
There are many medical conditions that can make periods worse: PMS, PMDD, dysmenorrhea, PCOS, hormone imbalances, endometriosis, fibroids, pelvic inflammatory disease, anemia, other nutrient deficiencies, cervical stenosis, adenomyosis. Psychosocial factors can also make periods more uncomfortable: cultural stigma around periods, history of sexual abuse, bullying. Girls who lack adequate support from female figures (eg. mother, aunt, older sister) will also have a harder time accepting and working with the physical and mental discomfort associated with their periods.
Providers should normalize the awkwardness and discomfort of menarche; identify any of these factors that may be worsening it; and provide referrals or interventions as needed to alleviate contributing factors to the discomfort.
Ultimately, all natal females will have to deal with their reproductive systems, which include menstruation. Failure to do so will result in worse consequences. Females who never learn to accept their reproductive systems, and instead take cross-sex hormones, will ultimately have to deal with vaginal atrophy, painful intercourse, painful urination, inorgasmia, and a host of other problems that will have much worse consequences for the individual over her lifespan. While no one enjoys the onset of menstruation, the best practice is to help girls accept and manage it.
We should maintain relationships with our clients to support their mental health, not to encourage harmful decisions.
-Medical or surgical treatments should not be indicated for adolescents.
-Parents/guardians should always be involved. Exclude “unnecessary;” clarify “harmful.”
A - The DSM-5 definition of gender dysphoria is largely based on sex stereotypes
B - yes
C - adolescents do not possess the cognitive and emotional maturity to make these decisions. There is no evidence based in neuroscience and psychology to support this.
D- yes
E - yes, but include all other health consequences
F - pubertal suppression is not a medically sound intervention
G - None of these interventions should be available to adolescents
H - see above
I hope this helps. Please take a moment to submit your own commentary to WPATH before December 16.
