Eli Coleman is a sexologist, psychologist, and a major figure in the world of gender medicine. On May 3, the 74-year-old University of Minnesota professor emeritus was deposed as a witness in Boe v. Marshall, a lawsuit challenging Alabama’s ban on sex “change” procedures for minors. Because Coleman was the chair and lead author of the World Professional Association for Transgender Health’s eighth and most recent “standards of care” (SOC-8), he was uniquely positioned to give a firsthand account of how the gender-medicine industry operates.
Coleman made several key admissions in his deposition. Notably, he did not denigrate key scholars who are skeptical of the gender-affirming model. He agreed, for example, that Stephen Levine, a psychiatrist who has served as expert witness on behalf of states imposing bans on pediatric transition, was not a “transphobe” but “a serious and careful researcher” with “numerous publications in this field.” He offered a similar assessment of Kenneth Zucker, the Toronto-based psychologist whose preference for a “wait and see” approach to childhood gender dysphoria led to accusations from activists that he promotes “conversion therapy.”
Additionally, Coleman conceded that “social factors” may “impact identity development and decision making in adolescents,” implying that at least some teens arrived at their transgender identity due to peer influences. While the professor emeritus seemed confident that such kids would be diverted from a medical pathway, he also said that he has never treated gender-distressed minors, hasn’t “recently” treated adults, and was unfamiliar with the everyday clinical realities at the University of Birmingham Pediatric Gender Clinic. He admitted to being “greatly” concerned at the prospect of gender clinics prescribing puberty blockers or cross-sex hormones after only a single visit. “And in the case of adolescents, how could you have a multidisciplinary assessment in one session? Can’t do it,” Coleman said.
A Reuters investigation from 2022 found at least seven pediatric gender clinics doing exactly that. In November, court testimony revealed that assessment times at the Gender Multispecialty Service at Boston Children’s Hospital, widely considered to be one of the most conservative such institutions in the country, had been cut down to a mere two hours.
The most significant of Coleman’s admissions, however, concerned WPATH’s failure in developing its “standards of care” to adhere to basic conflict-of-interest (COI) management protocols, which Coleman and WPATH recognized as essential to the production of trustworthy recommendations. This may seem esoteric, but it directly undermines WPATH’s professed commitment to the principles of evidence-based medicine. To understand WPATH’s failure, one must understand the proper way for guideline-producing organizations to manage conflicts of interest.
Groups developing medical guidelines are supposed to follow three steps when faced with conflicts of interest.
First, prospective members of a guideline-development group must disclose any COIs, ideally defined clearly on forms that candidates submit to the group’s selection committee. Conflicts can be financial as well as intellectual (“nonfinancial”), the latter of which include “academic activities that create the potential for an attachment to a specific point of view that could unduly affect an individual’s judgment about a specific recommendation.” Coleman agreed in his deposition that “A person whose work or professional group fundamentally is jeopardized or enhanced by a guideline recommendation is said to have intellectual conflict of interest.”
At this stage in the process, committees must also avoid even the appearance of undue influence. Karen Robinson, a Johns Hopkins University methodologist whom WPATH hired to conduct systematic reviews of evidence and advise on conflict-of-interest management, wrote in an email to SOC-8 members that conflicts can include anything that “could reasonably be perceived as interfering with [] full and objective decision-making” in guideline development. She added that this can include “being an investigator on studies likely to be considered in developing the recommendations or being a member of a group that did or may issue policy or recommendations related to SOC8 work.” Robinson noted that she “would expect many, if not most, SOC8 members to have competing interests.”
The imperative to avoid the actual as well as apparent COIs is even greater when selecting the chairs of a guideline committee. The National Academy of Medicine (NAM), whose standards for guideline development Coleman claimed guided WPATH’s process, specifies that a “chair or cochairs should not be a person(s) with COI.” Some experts in evidence-based medicine, such as McMaster University’s Gordon Guyatt, recommend having methodologists (e.g., epidemiologists) lead the process in guarded consultation with conflicted clinicians. By this standard, Coleman should never have been selected to lead SOC-8 in the first place, as we shall later see.
In the second phase of the conflict-management process, guideline committees review and decide how to manage candidates’ COI disclosures. “Optimally,” NAM states, guideline-development groups should not have conflicted members. However, “the most knowledgeable individuals regarding the subject matter . . . are frequently conflicted.” If input from conflicted individuals with “unique knowledge” is needed, NAM recommends that committees engage such individuals as “consultants” and “reviewers,” not as members of the guideline-development group. If the committee nevertheless feels the need to bring conflicted members into the group itself, these “should represent not more than a minority” of its composition. Conflict-of-interest management is supposed to be an ongoing process; a guideline group member may not have COIs at the start of the process but then develop them later on, before the guideline is finished.
In the final stage, groups declare COIs in the published guidelines, along with a description of how the guideline committee managed those conflicts. Clinicians who rely on medical guidelines, and patients who put their trust in those clinicians, have an obvious interest in knowing whether those who make recommendations stand to benefit from them personally or professionally. They also have an interest in knowing whether a guideline-development committee made a sincere effort to balance the perspectives of its members, or whether, instead, it stacked the deck by selecting only members committed to one approach. “Panel stacking is a threat to consensus statement validity,” as an article in the Journal of Clinical Epidemiology declares. WPATH acknowledges in SOC-8 that its recommendations regarding the treatment of minors rely on consensus rather than on systematic appraisal of evidence.
For experts in evidence-based medicine, credible and transparent COI management is a bedrock of any trustworthy medical guideline. It is at least as important as ensuring that clinical recommendations are grounded in a systematic review of the available evidence. This emphasis on transparency stems chiefly from contemporary medicine’s commitment to the value of patient autonomy. Patients cannot give informed consent if the recommendations that they agree to (or reject) conceal potentially relevant information, such as improper motives among guideline developers.
In a 2022 article titled “Enhancing the trustworthiness of the Endocrine Society’s Clinical Practice Guidelines,” published in its Journal of Clinical Endocrinology & Metabolism, the Endocrine Society, whose clinical practice guideline on gender medicine is cited alongside WPATH’s as authoritative, explicitly recognized the dilemma outlined by NAM. Subject-area experts, it said, should be kept at arms-length; “guidelines will achieve full credibility via methodological rigor and transparency.”
By Coleman’s own admission, WPATH knowingly violated these basic requirements for COI management and proceeded to conceal those violations from the public. As he disclosed to Roger Brooks, the deposing attorney, “most” of the SOC-8 authors had conflicts of interest, whether financial, intellectual, or both. In a separate deposition, Marci Bowers, the former president of WPATH and a coauthor of SOC-8, went further, attesting that it was “absolutely” “important for someone to be an advocate for [gender transition] treatments” to be considered for participation in SOC-8’s development.
SOC-8’s disclosure section states the following:
Conflict of interests were reviewed as part of the selection process for committee members and at the end of the process before publication. No conflicts of interest were deemed significant or consequential.
Selection of the SOC-8 committee members was done in May of 2017 or 2018, according to Coleman (who couldn’t remember the exact year). However, the COI disclosure forms were not due until December 2018, after committee members were selected, not “as part of the selection process.” Coleman confirmed this in the deposition. A day before the forms were due, Karen Robinson, the advising methodologist, wrote to the SOC-8 committee that “Disclosure, and any necessary management of potential conflicts, should take place prior to the selection of guideline members. Unfortunately, this was not done here.”
Coleman testified that he knew “most” members of SOC-8 had conflicts. However, he and his co-chairs deemed these conflicts to be neither “significant” nor “consequential.” Therefore, they thought, WPATH did not need to specify how, if at all, they were managed, and did not need to disclose them in the relevant section of the published guideline. Coleman insisted that Robinson’s guidance influenced these decisions. (Robinson, who privately complained about WPATH suppressing her team’s evidence reviews according to court records, did not respond to my request for comment.)
Is Coleman correct that in his response to Brooks that his committee used a “rigorous” and “transparent” process when drafting SOC-8?
To answer that question, start with the fact that Coleman himself had conflicts of interest—a clear violation of the NAM’s requirement that guideline-development leaders, who select participants and preside over the COI management process, should themselves be free of conflicts. Coleman has numerous publications advocating for greater access to medical transition and was the lead author of WPATH’s previous “standards of care,” which means he has intellectual conflicts as defined by both NAM and Karen Robinson. Coleman has also benefited personally and professionally from large donations by the Tawani Foundation to the University of Minnesota’s Institute for Sexual and Gender Health, which Coleman “spent many years of [his] professional life building up, [and] which was . . . recently renamed” in his honor. The chair of the Tawani Foundation, Jennifer Pritzker, is a transgender-identifying billionaire who has given millions in grants to prop up the U.S. gender industry. Coleman was aware that Tawani had provided the “great bulk of the out-of-pocket expense” that went into development of SOC-8.
Asked what steps he and his co-chairs—Asa Radix and Jon Arcelus—took to ensure that they “did not have any financial conflict of interest,” Coleman responded that “it is very customary that the committee members or those involved in developing the guidelines are involved in that care.” Customary? Perhaps. Consistent with NAM’s standards? Absolutely not. Those standards explicitly say that individuals with “clinical involvement” in an area of medicine “can share their expertise with the GDG [guideline development group] as consultants . . . but generally should not serve as members of the GDG.” Here again, Coleman claimed that the decision was in keeping with Karen Robinson’s guidance.
Other conflicts among the SOC-8 developers were at least as pronounced. Marci Bowers, the former WPATH president who contributed to the SOC-8 chapter on surgery, admitted in a separate deposition to making over $1 million from performing gender surgeries during 2023. Bowers has been a strong advocate for medical transition of minors and gained notoriety for performing vaginoplasty on Jazz Jennings. The SOC-8 declares no conflicts for Bowers.
NAM defines financial conflicts of interest as activities that include, among other things, “clinical services from which a committee member derives a substantial proportion of his or her income” and “serving as a paid expert witness.” Dan Karasic, a psychiatrist who chaired the mental health chapter, and Loren Schechter, a surgeon who co-led the surgery chapter and contributed to the “non-binary” chapter were both engaged as paid expert witnesses in federal lawsuits involving gender medicine when selected to participate in SOC-8. Both had a direct financial stake in SOC-8 supporting their testimony as expert witnesses.
In his deposition, Coleman confirmed that Karasic had requested that a “medical necessity” statement be added to SOC-8, which would trigger insurance coverage and which has legal implications. In addition to serving as expert witness, Schechter, WPATH’s current president-elect, is a plastic surgeon who specializes in, and derives income from, gender surgery. No conflicts are declared for Karasic and Schechter in SOC-8.
Other authors of SOC-8, including Joshua Safer, Stephen Rosenthal, and Annelou de Vries, are among the pioneers in “gender-affirming care” and have spent years building up professional reputations and personal practices around the medicalized approach. Diane Ehrensaft has published books advocating for gender transition (NAM includes “royalties” in its examples of financial conflicts) and has served as an expert witness in lawsuits involving social transition in schools. But according to Coleman, none of these clinicians have conflicts that are “significant or consequential.”
At one point in the deposition, Coleman confessed to Brooks that the “WHO [World Health Organization] right now is developing guidelines for transgender health care, and I know the committee members, and I know they have conflicts of interest that don’t follow their own guidelines.” WHO guidelines for conflict-of-interest management resemble those of the National Academy of Medicine. A recent investigation by BMJ, a British medical journal, found that WHO’s ongoing transgender guideline process was tainted by unmanaged conflicts of interest and associations with WPATH members, further evidence that WPATH intends to globalize its approach by colonizing international health bodies.
I asked Yuan Zhang, a professor of clinical epidemiology who specializes in evidence-based medicine and who trained at McMaster University, home of evidence-based medicine, whether he agreed with Coleman and WPATH’s approach in managing conflicts. “These cases are absolutely examples of significant and consequential conflicts of interest,” Zhang told me. “SOC-8’s statement about COIs is simply misleading. WPATH should have established some reasonable and transparent policy to manage these conflicts.”
There is deep irony in WPATH’s mercenary approach to COI management. Contemporary gender medicine has embraced a consumerist ethos that seeks to eliminate all “gatekeeping” to drugs and surgeries and make these interventions available based on “informed consent.” This approach reduces doctors to vendors and medical interventions to consumer goods. It does so in the name of human autonomy, defined, increasingly, as the satisfaction of patient wants.
Coleman’s deposition, by contrast, reveals a shocking lack of concern for COI management and transparency in the development of SOC-8, the leading medical guideline in transgender medicine. The organization not only failed to manage COIs but rather deemed them qualifications for participation. WPATH made no effort to balance the SOC-8 roster with clinicians advocating for a non-medicalized approach to gender-related distress. When asked about a clinical psychologist’s claims that WPATH suppresses dissent, Coleman told Brooks that he found her allegations “disconcerting.”
Nor did WPATH solicit input from detransitioner advocates or skeptical parents, who bring critical perspectives on care delivery in this area. This was the very definition of a stacked deck. Making matters worse still, SOC-8 states that its recommendation passed through a Delphi process of “expert consensus” building (since, it claims, systematic reviews of the evidence are “not possible”), yet Coleman admitted in the deposition that when his committee decided to remove age minimums for political reasons, “we did not send those through another Delphi.”
As a result of these failures, WPATH led patients—adults as well as minors and their parents—to make irreversible medical decisions based on false pretenses. Regardless of whether these patients are satisfied with their decisions, they have not exercised autonomy in any meaningful sense of the word. WPATH has failed to adhere even to its own reductionist and consumerist understanding of medical ethics.
As for Coleman, he is sticking to his guns. “When developing the SOC-8, we followed the most rigorous protocol in the world to ensure these standards reflect scientific evidence and meet the needs of transgender patients,” SOC-8’s lead author wrote in the Dallas Morning News in 2023. “When it comes to gender-affirming care, it’s time we trust the experts.”
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