The World Health Organization has faced widespread criticism since it announced plans to create a treatment guideline for “Trans and Gender Diverse People” in June 2023. Critics have charged the WHO with rushing the guideline-development process, stacking the committee responsible for crafting the recommendations, and working backward from a predetermined conclusion. While the organization has made occasional tactical retreats, it appears poised to endorse so-called gender-affirming care (GAC)—to the detriment of people with gender dysphoria.
In December, the WHO released the biographies of its guideline-development-committee’s membership. The list featured several professionals affiliated with the now-disgraced World Professional Association of Transgender Health (WPATH), which has been embroiled in various scandals, including allegedly suppressing research that contradicted its support for “gender-affirming” care. That announcement drew widespread pushback, and prompted the WHO to add six proposed members to the working group. Despite those additions, the committee remains plagued by intellectual and financial conflicts of interest, related to support for the “affirming” model of care.
The following month, the WHO announced another retreat. In a January 2024 FAQ, the organization clarified that its proposed guidelines would apply only to adults, not children and adolescents. “[T]he evidence base for children and adolescents,” the WHO conceded, “is limited and variable regarding the longer-term outcomes of gender affirming care.”
This was a step in the right direction, but the FAQ document made clear that the WHO was putting the cart before the horse. In justifying the need for new clinical guidance, the organization states that “[m]any [health-care] settings lack policies to facilitate access to inclusive and gender affirming care.” The WHO suggests that such policies are consistent with the human rights principle of the “right to health,” but it cannot assert that “affirming 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 is worth noting that, as the Society for Evidence Based Gender Medicine points out, there have been “sharply rising rates” of trans-identification in recent years among adolescents and young adults. Though the WHO is opting not to weigh in on adolescents, the epidemiological profiles of dysphoric adolescents and young adults are similar—often, females with psychiatric comorbidities and developmental or neurocognitive issues. Unconditionally recommending “affirming care” for young adults, who often have similar clinical presentations to adolescents, could have disastrous consequences.
Lest the WHO’s endorsement of “affirming care” be dismissed as an aberration, the organization underscored its position in a July 2024 revision to 2022 guidelines on HIV and sexually transmitted infection prevention. While the update was ostensibly about promoting health interventions for STIs among the trans-identified, the WHO uses it as a platform to smuggle in the two major tenets of its larger adult guideline agenda: expanding access to “affirming care” and advocating for the legal recognition of self-determined “gender identity.”
First, the guideline speculates that allowing trans-identified people to choose their legal identity will reduce stigma in health care. The WHO does not, however, analyze the impact of allowing legal self-identification on women and sex-segregated spaces. Second, without a supporting citation, the WHO asserts that “[a]ccess to safe and evidence-based gender-affirming care should be seen as central to trans and gender diverse people’s broader health.” The updated guideline barely tries to establish a connection between STI initiatives and “affirming care,” and takes for granted that such “care” will improve “broader health.” Once again, no supporting citations are offered for these claims.
Notably, the STI guidance refers to “gender incongruence,” rather than gender dysphoria. This is in keeping with a similar change in the WHO’s International Classification of Diseases, Eleventh Edition, which insurance companies rely on for diagnostic categories, where “gender incongruence” has replaced “gender dysphoria,” and is now classified as a sexual-health, rather than a mental-health, condition. As I have written previously, the “gender-incongruence” framework removes distress as a key feature of the trans-identified person’s condition and aims to destigmatize transgender identification more broadly.
There is a have-your-cake-and-eat-it-too logic to “gender incongruence.” By keeping it in the ICD-11, the WHO allows trans-identified persons’ condition to remain eligible for insurance reimbursement, while sidestepping questions of whether “affirming care” has any demonstrated clinical benefit. If “gender incongruence” is not a mental-health condition, and distress is not a necessary feature, then the cultural narrative of “affirming care” as “lifesaving” and “medically necessary” also breaks down.
Defenders of the gender-incongruence framework 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. Prioritizing patient autonomy, for example, should not come at the expense of the principles of beneficence, non-maleficence, and justice.
The principle of justice, or fairness, demands that we hold gender medicine to the same standards as other areas of medicine. This means that we owe it to gender-distressed patients of all ages to ensure that our practices are informed by the highest standards of scientific evidence, instead of solely appealing to the value of patient autonomy.
Evidence for the benefits of “affirming care,” both for adults and minors, is limited. The evidence review funded by WPATH, for instance, which evaluated the benefits of “affirming care” in both children and adults, concluded that the strength of evidence for benefits is low due to the nature of the study designs, the small sample sizes, and the existence of confounds with other interventions. Crucially, one of the main reasons why Dutch researchers felt compelled to innovate with pediatric sex-trait modification procedures in the first place was the failure of sex-reassignment to improve psychological health in adult transitioners.
To exercise their autonomy fully, patients need to proceed according to a truly informed consent process that lets them make decisions with an accurate account of benefits and risks. A treatment guideline for adults that recommends “affirming care” without a systematic review, as the WHO appears poised to do, is inconsistent with the four principles of clinical ethics.
A lot can change between now and the finalization of the WHO’s treatment guideline for adults, but the organization’s conduct leaves little room for optimism. If the WHO endorses expanded access to “affirming care” without assessing the strength of the evidence for benefits and harms, it would be violating its own handbook on guideline development, which advises against “discordant recommendations.”
Strong recommendations should be based on strong evidence. Without valid evidence that “affirming care” will help patients, the WHO’s endorsement would betray clinical ethics—along with the gender-distressed patients whom its guideline is meant to serve.
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