Poor standards of transgender health care threaten transgender health

I will never forget the hand sanitizer provided for election workers to use in 2020, at the height of the COVID-19 pandemic. Whenever I applied it, I would hold my breath until it dried. One whiff could make a sensitive person gag. An intentional sniff could send them to the floor. Of course, the product was quite literally 160-proof grain alcohol with an added splash of glycerin and peroxide. It could find every paper cut I’d had since the eighth grade.

It wasn’t a gel, but a liquid. It dripped everywhere and spilled easily. Precinct Election Officials were warned that if the check-in slips each voter signed were to have hand sanitizer dribbled on them, chemicals in the paper would react, rendering affected print unreadable. If it spilled on the ballots … oh, boy.

Why, then, would the producers of the product not add a gelling agent to make our spray bottle moonshine easier to use? They couldn’t. For local liquor distillers to be allowed to produce it, temporary FDA rules required that it be prepared “consistent with World Health Organization recommendations,” which did not permit a “thickening agent” in alcohol-based hand sanitizers.

Why was the WHO the decider of recommendations? Because by virtue of its mission to “promote health” and “keep the world safe,” among others, its guidance has been regarded as the gold standard in matters of global public health.

Many industries follow policies and/or guidelines set by some organization seen as the expert authority in its particular subject. That’s especially true for medicine — virtually every specialty in the health care field has a professional association dedicated to setting and upholding standards of care in that field.

For the treatment and care of people with gender dysphoria, the World Professional Association for Transgender Health (WPATH) has long been regarded as the global authority in the treatment of gender dysphoria. Founded in 1978, it was originally called the Harry Benjamin International Gender Dysphoria Association. One year after forming, the organization published its Standards of Care for transgender health, or SOC. Two updated versions of the SOC followed in as many years, followed by a fourth in 1990.

A disagreement over hormone replacement therapy commencement guidelines between the organization’s president and Dr. Stephen Levine, the chair of the committee for the fifth version (SOC5) resulted in the president hastily commissioning SOC6 in 2001. SOC6 was nearly identical to SOC5 with a notable change away from Dr. Levine’s recommendation about HRT. In 2002, having reached a “regretful conclusion that the organization and its recommendations had become dominated by politics and ideology, rather than by scientific process, as it was years earlier,” Dr. Levine resigned his membership from the organization then still known as HBIGDA.

HBIDGA would become WPATH in 2007 and release SOC7 in 2012. SOC7’s recommendations included gonadotropin-releasing hormones, more commonly called puberty blockers, for kids as young as 11 or 12. SOC7 described puberty blockers as “fully reversible interventions” but only two pages later acknowledged that there was no long-term data on the effects of puberty blockers, stating “ … the long-term effects can only be determined when the earliest treated patients reach the appropriate age.”

The most recent version of WPATH’s standards of care, SOC8, was released in September 2022. A leaked draft version showed several concerning changes in minimum age recommendations: from 16 to 14 years of age for cross-sex hormones (different from puberty blockers and with permanent effects,) 15 years for masculinizing mastectomies, and 17 years for surgeries including but not limited to removal of the uterus or testicles and vaginoplasty, known as “bottom surgery.”

Given the risks associated with hormones and the permanence of surgery, those are some controversial standards, to say the least.

Almost immediately after SOC8 was released, WPATH would issue corrections, removing the minimal age recommendations entirely.

As WPATH’s standards of care loosen to accept treatments of increasing severity on continuously younger patients, scrutiny of the organization has grown. Last week, a report called “The WPATH Files: Pseudoscientific surgical and hormonal experiments on children, adolescents, and vulnerable adults” was released by Environmental Progress, an organization founded by environmental activist and investigative journalist Michael Shellenberger of Berkeley, California.

The report, authored by EP staffer Mia Hughes, accuses WPATH of using its position as global leader in gender-focused medicine to push standards of care that defy ethics and flout the standards of evidence-based medicine in favor of activism — while privately, many of its own members lament their patients’ frequent inability to properly consent and acknowledge the painful complications in which their treatments can result. To support that claim, a cache of communications from WPATH’s internal messaging forum and a leaked video recording of a panel discussion with an accompanying transcript are included in the 242-page report, which is loaded with anecdotes and summaries to put them in context.

Reading even just a couple of them makes for an unpleasant experience. But the discussion will never be complete if it excludes the hard truths about these standards of care.

In one exchange between WPATH members, a gynecologist writes of a patient who transitioned from male to female and had undergone “full depth” penile inversion vaginoplasty, where the male penis is peeled like a banana and a “neovagina” is formed. A year after surgery, the patient complained of ejaculate through her urethra that was “bothersome.” The patient had likely not realized that although the removal of testicles meant no longer producing sperm, she would still produce (and expel) semen.

A urologist responded. “After vaginoplasty, the muscles to expel the fluid are gone so the fluid won’t come out as quickly, but the (sic) will likely still have the same volume of fluid.

“To my knowledge,” the urologist continued, “there is no surgeon in the world that removes prostate and seminal vesicles at the time of vaginoplasty — too invasive and risk of untreatable urinary incontinence. I don’t think there is a remedy.”

So, despite the painful lengths to which the patient has gone to alter her male constitution to that of a female, she will still ejaculate like a man for the rest of her life.

A third participant chimes in. “As a woman of trans experience who had bottom surgery 40 years ago, I say enjoy the ride. In my experience, it’s the ultimate sign of orgasm … what’s not to like?”

A presumably transgender user of social media site Reddit saw that same exchange while reading the WPATH report and felt compelled to voice their thoughts.

“I was not expecting my surgeon to be included in the article,” wrote the anonymous Redditor. “It is so clear that these patients were not aware of what they were getting from surgery. I wonder how many other trans women weren’t aware that they can’t fully escape their biological sex, but by all means, ‘enjoy the ride.’”

Sexual function is a common topic in any medical or surgical transition, and the implications can’t be overstated — especially when it comes to informed consent. Many gender-affirming procedures endorsed by WPATH carry lifelong implications that patients struggle to understand at the time.

In a thread titled “Best Practices for Puberty Suppression,” current WPATH president Dr. Marci Bowers writes, “We do not fully understand the onset of orgasmic response and blockers make this a major question.”

It is widely cited that puberty blockers pose a risk to sexual function, a concept that simply can’t be appreciated by a gender-confused 12-year-old seeking to delay puberty.

Then there’s fertility. In the video of a WPATH workshop, a pediatric endocrinologist shares his concern: “ … like, it’s always a good theory that you talk about fertility preservation with a 14-year-old, but I know I’m talking to a blank wall.”

The endocrinologist continues, “Apparently last week at the Pediatric Endocrine Society, some of the Dutch researchers … gave some data about, um, young adults who had transitioned and reproductive regret, like regret, and it's there … and I don't think any of that surprises us.”

A clinical psychologist echoes the concern. “Um, in some ways, the stuff that you need to do to be able to preserve your fertility might be beyond kind of what a youth, where a youth is at in terms of their sexual development, and yet, that's kind of what's needing to happen and, um … yeah.”

Those are just a few of many instances detailed in the WPATH report. With such controversial standards and complicated ethics, it shouldn’t surprise anyone that countries including Finland, Sweden and the U.K. have abandoned WPATH standards in favor of stronger, safer guidelines for transgender medical care.

I don’t expect the U.S. to join the departure any time soon. Not as long as large numbers of Americans remain enmeshed in an ideology that views anything short of total and eager affirmation as unbridled bigotry. Nobody will suffer the consequences of it more than trans people themselves as the care they seek remains marred in criticism and controversy.

It’s so easy to attribute it all to hostility and hate. It’s harder to face painful truths about the ethical disasters disguised as medicine. But if we fail to face them, we can’t say we weren’t warned.

Comments: 319-398-8266; althea.cole@thegazette.com