Genspect concerns submitted to the World Health Organisation (WHO) regarding the announcement of the development of a guideline on the health of trans and gender diverse people

Genspect is an international organisation that promotes a healthy approach to sex and gender. Our organisation includes professionals, trans people, detransitioners and parent groups who work together to advocate for a non-medicalised approach to gender diversity. Our vision is to move beyond a medical understanding of gender identity and gender distress that typically leads to invasive medical interventions, and toward a deeper understanding of gender and identity. We believe that there are many routes that may lead to the development of distress over an individual’s sex and gender. Equally, there are just as many routes out of such distress.

Genspect has grave concerns regarding certain aspects of the recent announcement by the World Health Organisation of the development of a guideline on the health of trans and gender diverse people. Elements of the proposed focus of the guideline along with the membership of the Guideline Development Group (GDG) suggest an inherent bias towards a single perspective, one that is contrary to many of the core principles of WHO guidance development (World Health Organization, 2014) and that will undermine the integrity of and public confidence in the resulting guideline.

Bias in favour of gender-affirming care in guideline focus & GDG

The announcement states that one of the five areas the guideline will focus on is the “provision of gender-affirming care, including hormones“. Neither this announcement or a recent WHO peer-reviewed publication regarding improving the health of trans and gender diverse people (Macdonald et al., 2022), acknowledge the significant professional disagreement worldwide regarding gender-affirming care (Block, 2023) or the mounting evidence of significant numbers of detransitioners who feel they were harmed by gender-affirming care (D’Angelo, 2018; Expósito-Campos, 2020; Exposito-Campos & Roberto, 2021; Hall et al., 2021; Irwig, 2022; Jorgensen, 2023; Littman, 2021; Littman et al., 2023; Marchiano, 2021; Vandenbussche, 2021; Withers, 2020) or the significant medical complications associated with gender-affirming care (Anacker et al., 2020; Baldassarre et al. 2013, Biggs, 2021; Delgado-Ruiz & Swanson, 2019; Masumori & Nakatsuka, 2023; NICE, 2020a, 2020b; Nota et al., 2018).

Recent systematic reviews on gender-affirming care have identified low quality evidence, high risk of bias in study designs, small sample sizes, and confounding with other variables (Baker et al., 2021; Cass, 2022; Ludvigsson et al., 2023). Following national health department independent reviews, several progressive countries (Denmark, Finland, Sweden, the United Kingdom, Norway, the Netherlands, and France) have all recently changed course to restrict gender-affirming care for minors.

Since gender distress often begins in childhood or adolescence, and an individual’s social and medical gender transition (and in some cases detransition) journey can continue over a decade or more, gender-affirming care for minors and adults must be considered holistically as a continuum. In Ireland senior clinicians in the adult National Gender Service (NGS) have submitted a formal complaint to the Health Information and Quality Authority regarding harm they allege was done to children referred to a UK clinic providing gender-affirming care. The clinicians carried out assessments of these children when they “aged-into” the adult NGS and allege that: assessments carried out by the UK clinic were poor, that some children has been started on courses of gender-affirming treatment that were not appropriate, and that some children were having great mental health difficulties as a result.

Research consistently shows trans and gender diverse individuals have, on average, higher rates of autism, other neurodevelopmental and psychiatric diagnoses compared to the general population (Churcher Clarke & Spiliadis, 2019; de Vries et al., 2010; Kaltiala-Heino et al., 2018; Warrier et al., 2020). These overlapping factors present unique complexities. The need for medical transition does not occur within a vacuum, typically there are preceding events that should also be considered, as captured in the image below from the interim report from the UK Independent review of gender identity services for children and young people (Cass, 2022).

Guidelines for healthcare for trans and gender diverse adults must be considered within the wider context of childhood gender diversity, childhood development and specific emotional, cognitive developmental challenges common to many trans and gender diverse individuals at different stages of their journey through gender related distress.

According to the WHO Guideline Development Handbook “People with direct experience in managing the condition or problem addressed by the guideline and who will have a role in implementing the new recommendations − members of governmental and nongovernmental organizations, programme managers, health-care workers and other end-users of the guideline − should participate in the GDG” (p.26, World Health Organization, 2014). 11 of the 21 members of the current GDG are current or former senior members of groups (World Professional Association of Transgender Healthcare (WPATH), Global Action for Trans Equality (GATE), ILGA) that actively promote gender-affirming care. The membership of the Guideline Development Group (GDG) does not include any members representing the perspectives of professionals who are critical of gender-affirming care to balance the gender-affirming viewpoint and provide diverse perspectives (e.g. Genspect, CAN-SG, SEGM, Therapy First) as recommended in the WHO Guideline Development Handbook. The 2023 WPATH Standards of Care 8 cites rates of regret from gender-affirming care among detransitioners between 0.3% and 3.8% (Coleman et al., 2022), yet emerging evidence suggests much higher rates: 6% – 10% (Hall et al., 2021) and 30% (Roberts et al., 2022). The truth is the rates of detransition and regret are not known (Cohn, 2023) and further research is badly needed. At least 7 of the current 21 members of the GDG are or were recently, members of WPATH or affiliates of WPATH. Since the GDG membership is not balanced with members with different perspectives to the WPATH view of gender-affirming care, there is a significant risk that detransition concerns will not be given appropriate consideration within the guideline.

Genspect is the only organisation in the world that offers funding for therapy for detransitioners and people who have been harmed by medical transition. We established this service, Beyond Trans, in June 2021, and to date we have received hundreds of emails from people who either regret their medical transition or who have taken the very difficult decision to try to revert this process and to ‘detransition’.  For more information on detransition please see a wide range of detransitioners’ stories available from Genspect annual Detrans Awareness Day; detransitioner interviews on our website (e.g. Sinead Watson, Laura Becker, Lukasz Sakowski, Ethan, Chris, Steven A. Richards, M); and detransitioner stories in the mainstream media (e.g. Ritchie Herron, Chloe Cole, Keira Bell) and at our Bigger Picture conferences in Killarney, Ireland in April 2023 and Colorado, USA  in November 2023.

According to the WHO Guideline Development Handbook “Individuals who are likely to be affected by the intervention(s) or approach(es) under consideration in the guideline − or their representatives − bring invaluable perspectives to the guideline development process” (p.27, World Health Organization, 2014). At least 10 of the members of the GDG are themselves trans or gender diverse and are advocates for gender-affirming care, yet the GDG does not include a single detransitioner who feels they were harmed by gender-affirming care. The overwhelming lack of balance in the GDG between the lived experience of individuals who feel they have benefited from gender-affirming care versus those who feel they were harmed by gender-affirming care is in direct conflict with the WHO’s own recommendation to involve “service users in groups developing guidelines helps to ensure that…the balance of benefits and harms of the intervention is appropriately considered when recommendations are formulated” (p.27, World Health Organization, 2014).

The WHO Guideline Development Handbook says the GDG should also include “other technical experts as required”. Many detransitioners who feel they were harmed by gender-affirming care have taken legal action against their care providers (e.g. Bell v Tavistock, Cole v Kaiser Foundation Hospitals Inc). These legal cases are impacting clinical care (Halasz & Amos, 2023; Helyar et al., 2021) and therefore legal expertise should also be included within the GDG.

Given the high prevalence of autism, neurodevelopmental and psychiatric diagnoses among gender diverse individuals the GDG also appears to be lacking in expertise in these areas with biographies of just 2 of the 21 members including professional mental health expertise and no members with expertise in autism or neurodiversity. 

Bias in favour of legal recognition of self-determined gender identity in guideline focus & GDG

The WHO announcement states that another of the five areas the guideline on the health of trans and gender diverse people will focus on is the “legal recognition of self-determined gender identity“. The wording suggests an inherent bias in favour of self-determined legal gender recognition rather than legal gender recognition with some safeguards or qualifications (e.g. a requirement for evidence of a clinical diagnosis of gender dysphoria). Self-determined legal gender recognition is relatively new, in Europe the earliest introduction of self-determined legal gender recognition was in Denmark in 2014, hence the evidence of impacts, benefits and harms both to those accessing self-determined legal gender recognition, and to other impacted groups in society is very limited. Self-determined legal gender recognition is also a complex and controversial issue. Women’s groups have highlighted that self-determined legal gender recognition has impacts on the dignity and safety of all women and girls, and their access to single sex spaces as well as their freedom from violence. The UN Special Rapporteur on violence against women and girls has stated that “a right to legal gender recognition does not imply a right to unregulated self-identification of gender identity without appropriate safeguarding and risk assessment”.

In Ireland, self-determined legal gender recognition was enacted in 2015. In 2019 a case arose of “a pre-operative, pre-hormone therapy, male-to-female transgender prisoner” convicted of ten counts of sexual assault and one count of cruelty against a child who was committed to a women’s prison, in response to this case the chair of the Irish law society criminal law committee stated that the self-determined legal gender recognition law had placed the State in an “impossible position” with regard to transgender prisoners. An case arose in 2023 where a natal male transgender prisoner committed for threatening to rape, torture and murder had to be moved from the female prison estate to the male prison estate after prison officers raised safety concerns.

A document produced by transgender advocacy group IGLYO provides strategies for activists to introduce self-determined legal gender recognition for children and young people under the age of 18. One tactic is to avoid public scrutiny “by trying to pass legislation ‘under the radar’” (p55), another is to “De-medicalise the campaign … De-medicalisation involves separating the legal gender recognition process from the public association with medical treatment or diagnoses”(p18) as IGLYO predict public apprehension about expanding gender recognition given this association.

Keeping medical transition separate from legal gender recognition may be politically expedient but there is some evidence that legal and medical transition are interrelated. In a 2018 public submission on behalf of the Royal College of Surgeons to an Irish government review of Ireland’s self-determined legal gender recognition legislation, experienced clinicians working with trans and gender diverse individuals reported that gender recognition certificates granted under self-determination were being presented by service users to gender clinics overseas as evidence of gender dysphoria to avoid having to undergo clinical assessment prior to accessing medical and surgical transition. This demonstrates that individuals who were granted self-identified legal gender recognition, used their legal status to progress their medical transition.

Professor Riittakerttu Kaltiala, a Finnish early adopter of paediatric gender transition and now a reformist critic, has pointed out that she was “really worried that the WHO—which should represent responsibility for the health of all people—appears to have committed itself to a fully political initiative promoting treatments based on no evidence.”

In recent years a relatively new and distinct clinical presentation of late-onset gender dysphoria has been identified, and evidence is emerging that social influences (social media, social and peer contagion, etc.) can contribute to its appearance in some individuals (Littman, 2018, 2021; Sapir et al., 2023). There is evidence that following some initial short term transition euphoria, regret and detransition can take between three (Littman, 2021) and ten years (Wiepjes et al., 2018) to emerge so until it can be confirmed that legal societal influences are not contributing to more individuals proceeding down a path of medical transition that they may later regret, it is prudent to exercise caution. A good deal of further research is required about this issue and it is important to recognise that since brain maturation (Arain et al., 2013) and identity development continue into early adulthood, these issues impact young adults aged between eighteen and twenty-five.

At least 11 of the 21 members of the GDG are current or former senior members of groups (World Professional Association of Transgender Healthcare (WPATH), Global Action for Trans Equality (GATE), ILGA), these organisation all actively advocate for self-determined legal gender recognition. The membership of the Guideline Development Group (GDG) selected by WHO technical staff does not include any members representing the perspectives of those who have concerns regarding self-determined legal gender recognition for example; Genspect, CAN-SG, Thoughtful Therapists, Therapy First, Sex Matters, SEGM, DoNoHarm, LGB Alliance, Women’s Place UK, Fair Play for Women , Gender Dysphoria Support Network and many others. A good deal of concern has already been raised by these organisations about the impact of self-determined legal gender recognition on the safety and dignity of women and girls; about internalised homophobia and the high numbers of ‘pre-gay’ children expressing a desire to medically transition; about the social influences contributing to increasing numbers of individuals experiencing gender distress medically transitioning and subsequently regretting medical transition; about the impact of co-morbidities on individuals’ understanding of medical transition and about other related issues. Recognition of these voices is imperative to balance the WPATH, GATE, ILGA viewpoint and thus provide diverse perspectives as recommended in the WHO Guideline Development Handbook (World Health Organization, 2014).

Genspect urges the WHO to:

1. Pause this process until a more comprehensive consultation is carried out.
2. Review the focus areas of the guidelines to recognise diverse viewpoints among professionals, advocacy groups and service users to remove any inherent bias regarding healthcare for trans and gender diverse individuals and legal gender recognition to ensure that the guidance does not make pre-emptive assumptions and considers all relevant evidence and perspectives.
3. Review the membership of the current GDG to ensure the GDG a balance of diverse viewpoints of professionals and those with lived-experience in accordance with the WHO Guideline Development Handbook.
   • Specifically to include clinicians who advocate for a more exploratory, open-minded perspective for gender dysphoria.
   • Specifically to include stakeholders who understand the harm that can occur as a result of medical transition.
4. Endeavor to ensure that the guideline development process in this controversial and highly sensitive area is as transparent and balanced as possible to reassure all perspectives that their views are being fairly represented. For example, ensuring that the GDG, external review group, systematic review team and observers represent a balance of diverse viewpoints in accordance with the WHO Guideline Development Handbook and ensuring transparency of the process wherever possible.

The World Health Organization is a trusted source for non-biased guidelines that can be relied upon to protect human and promote health equity. Given the considerable controversy in this field, we urge WHO to take the time to further consider the unintended consequences of their current approach to the development of a guideline on the health of trans and gender diverse people.

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