The World Health Organization has faced widespread criticism since it announced plans to create guidelines for treating “transgender and gender nonconforming people” in June 2023. Critics have accused the WHO of rushing the guidelines, overstaffing the committee responsible for developing the recommendations and working backward from a predetermined conclusion. Although the organization has made occasional tactical withdrawals, it appears ready to support so-called gender-affirming care (GAC) — to the detriment of people with gender dysphoria.
In December, WHO released biographies of the members of its guidelines development committee. The list included several professionals associated with the now-disgraced World Professional Association for Transgender Health (WPATH), which has been embroiled in various scandals, including allegedly suppressing research that contradicted its support for “gender-affirming” care. The announcement sparked widespread outcry and prompted WHO to add six proposed members to the working group. Despite these additions, the committee remains plagued by intellectual and financial conflicts of interest related to its support for “gender-affirming” care.
The following month, WHO announced another withdrawal. In a January 2024 FAQ, the organization clarified that its proposed guidance would apply only to adults, not children and adolescents.[T]“The evidence base for children and adolescents,” the WHO acknowledged, “is limited and variable regarding long-term outcomes of gender-sensitive care.”
This was a step in the right direction, but the FAQ document made it clear that WHO was putting the cart before the horse. In justifying the need for new clinical guidelines, the organization states that “[m]everyone [health-care] The WHO suggests that such policies are consistent with the human rights principle of the “right to health,” but cannot claim that “affirmative care” is consistent with the “highest attainable standard of mental and physical health” without systematically reviewing the evidence base and analyzing the benefits and harms of these procedures.
It’s worth noting that, as the Society for Evidence Based Gender Medicine points out, there have been “skyrocketing rates” of trans-identification among adolescents and young adults in recent years. While the WHO doesn’t want to judge adolescents, the epidemiological profiles of dysphoric adolescents and young adults are similar—often women with psychiatric comorbidities and developmental or neurocognitive issues. Unconditionally recommending “affirming care” to young adults, who often have similar clinical presentations to adolescents, could have disastrous consequences.
Lest WHO’s support for “affirming care” be dismissed as an aberration, the organization emphasized its position in a July 2022 revision of its guidelines for preventing HIV and sexually transmitted infections. While the update was ostensibly about promoting STI health interventions for transgender people, WHO is using it as a platform to push two key principles of its broader adult guidelines program: expanding access to “affirming care” and advocating for legal recognition of self-determined “gender identity.”
First, the guidelines speculate that allowing transgender people to choose their legal identity will reduce stigma in healthcare. However, the WHO does not analyze the impact of allowing legal self-identification on women and gender-segregated spaces. Second, without substantiation, the WHO claims that “[a]Access to safe and evidence-based gender-affirming care should be seen as central to the broader health of transgender and gender nonconforming people.’ The updated guidelines barely attempt to establish a link between STI initiatives and ‘affirming care’, and assume that such ‘care’ will improve ‘broader health.’ Once again, no supporting citations are provided for these claims.
Interestingly, the STI guidelines refer to “gender incongruence” rather than gender dysphoria. This is consistent with a similar change in WHO guidelines International Classification of Diseases, Eleventh Editionthat insurance companies rely on in diagnostic categories, where “gender incongruence” has replaced “gender dysphoria” and is now classified as a sexual health condition, not a mental health condition. As I have written before, the “gender incongruence” framework removes suffering as a key feature of the transgender condition and aims to destigmatize transgender identification more broadly.
There is a “have-your-cake-and-eat-it-too” logic to “gender nonconformity.” By leaving it in ICD-11, WHO allows transgender conditions to continue to be eligible for insurance reimbursement while sidestepping the question of whether “affirmative care” has any proven clinical benefit. If “gender nonconformity” is not a mental health condition, and distress is not a necessary characteristic, then the cultural narrative of “affirmative care” as “lifesaving” and “medically necessary” also falls apart.
Defenders of gender nonconformity frameworks often appeal to patient autonomy to justify access to GAC. Indeed, patient autonomy—particularly for adults—is an important principle of clinical ethics, but it is not the only one. For example, prioritizing patient autonomy should not come at the expense of the principles of beneficence, nonmaleficence, and justice.
The principle of justice or fairness requires that we apply the same standards to gender medicine as to other areas of medicine. This means that we owe it to patients with gender issues of all ages to ensure that our practices are based on the highest standards of scientific evidence, rather than solely on the value of patient autonomy.
The evidence for the benefits of “affirmative care” for both adults and adolescents is limited. For example, a WPATH-funded evidence review that assessed the benefits of “affirmative care” for both children and adults found that the strength of the evidence for benefits was low due to the nature of the study designs, small sample sizes, and the existence of confounding factors with other interventions. Crucially, one of the main reasons that Dutch researchers felt compelled to innovate in pediatric sex modification procedures was the failure of sex reassignment to improve the mental health of adult transitioners.
To fully exercise their autonomy, patients must follow a truly informed consent process that allows them to make decisions with a careful balance of benefits and risks. Adult treatment guidelines that recommend “affirmative care” without systematic review, as the WHO seems prepared to do, are at odds with the four principles of clinical ethics.
Much can change between now and when WHO guidelines for adult treatment are finalized, but the organization’s course of action leaves little room for optimism. If WHO endorses expanded access to “affirmative care” without assessing the strength of the evidence for benefits and harms, it would violate its own guideline-writing manual, which discourages “discordant recommendations.”
Strong recommendations should be based on strong evidence. Without strong evidence that “affirming care” will help patients, WHO’s endorsement would be a betrayal of clinical ethics—along with the gender-sensitive patients its guidelines are intended to serve.
Photo: diegograndi / iStock Editorial / Getty Images Plus
#WHOs #Uncompromising #Stance #Sexual #Medicine