Bernard Lane: Experts exposed
Michael Barnett OAM
The people who drew up the best-known international guideline for gender medicine abruptly abandoned minimum ages for irreversible medical interventions after pressure from the Biden Administration, which is litigating in defence of the besieged “gender-affirming” treatment model.
The draft guideline’s thresholds—age 15 for mastectomy, for example, and 17 for hysterectomy—would “result in devastating legislation for trans care”, according to the office of Assistant Secretary for Health, Rachel Levine1, who identifies as a woman. “She [Dr Levine] wonders if the specific ages can be taken out.”
Internal communications from the World Professional Association for Transgender Health (WPATH) give insight into unguarded opinions, conflicts of interest and fears among members of the guideline development group for the 8th edition standards of care (SOC-8) issued in 2022.
One member’s email said: “[Dr Levine likes] the SOC-8 very much but she was very concerned that having ages (mainly for surgery) will affect access to healthcare for trans youth and maybe adults too. Apparently, the situation in the USA is terrible and she and the Biden administration worried that having ages in the document will make matters worse. She asked us to remove them.2”
Another WPATH member objected to this derailing of proper guideline process but conceded “it’s all about the messaging and marketing.”
The watchdog group Do No Harm, which opposes ideology in medicine, has launched a petition seeking Dr Levine’s resignation or dismissal, stating that the official “has deliberately endangered America’s children—putting politics ahead of children’s health.”
“Levine isn’t just ignoring the evidence. Levine is essentially saying that the transgender agenda matters more than evidence.”
The extraordinary material implicating America’s second highest health official is among documents filed by clinical psychologist and sex researcher James M Cantor3, an expert witness for the state of Alabama, which subpoenaed WPATH discussions around SOC-8 as it sought to defend its legislative ban on paediatric gender medicine before the US District Court4.
WPATH and its guidelines, cited by governments internationally as a guarantor of the quality and safety of care in paediatric gender clinics, have suffered a series of setbacks, including public statements of concern about rushed medicalisation by former US-PATH president Erica Anderson, the reputational damage of the WPATH files, and the emergence of independent systematic reviews in Europe exposing the weak evidence base and leading to restrictions on puberty blockers and cross-sex hormones.
“Having been vilified for speaking the truth for years, I take little consolation in my own vindication [by Dr Cantor’s work],” Dr Anderson, a gender clinician and trans woman, told GCN.
“More important is the giant step toward honesty and transparency, and that all can see what I’ve known in the genuine scepticism and dismay by others who went along with stonewalling and permitted politics to infect the review of evidence to develop best practices.
“What I have observed in professional societies concerning trans youth medicine has turned my stomach. The sickness that is trans ideology is now exposed. Next stop disinfectant—and truth and reconciliation. We must stop sugar-coating and call out the liars, sycophants and reckless narcissists. Safeguard the children.”
Video: Megyn Kelly talks to detransitioner Prisha Mosley
“While European health authorities have examined the science and concluded that medical transition for minors remains ‘experimental’ and of unproven benefit, terminology has been distorted in the US because the US lacks a public health care system and the terms ‘medically necessary’ and ‘experimental’ impact health insurance coverage. ‘Medically necessary’ justifies coverage for these procedures; advocates know or fear that the term ‘experimental’ will preclude coverage.”—Clinical psychologist Dr James M Cantor, expert report in Alabama’s case, 19 May 2023
“[Despite the lack of reliable comparative studies], numerous harms [of hormonal gender treatments] are either known, or reasonably anticipated, [including] sterilisation without proven fertility preservation options; permanent loss of capacity for breast-feeding in adulthood; lifetime lack of orgasm and sexual function.
Hormonal treatments during puberty interfere with neurodevelopment and cognitive development; substantially delayed puberty is associated with medical harms; elevated risk of Parkinsonism in adult females; reduced bone density.
Short-term/immediate side-effects of puberty blockers include sterile abscesses, leg pain, headache, mood swings, and weight gain. Long-term use of cross-sex hormones in adult transsexuals is associated with unfavourable lipid profiles (cholesterol and triglycerides) and other issues.
Unusual candour
De-identified emails cited by Dr Cantor show members of WPATH’s guideline development group conceding the lack of medical consensus in favour of puberty blockers5; the vulnerability of WPATH-cited studies to scrutiny by the Society for Evidence-based Gender Medicine; the risk of a “lax” SOC-8 allowing surgery-on-demand for adults; the danger of “predatory practices by some surgeons”; the likelihood of social influence as a driver of trans youth identity; the reality of detransition and regret; and the weak foundations of the 2018 affirmation-only policy6 from the American Academy of Pediatrics (AAP).
“Members of the WPATH guideline development group repeatedly and explicitly lobbied to tailor language of the [SOC-8] guidelines for the purposes of influencing courts and legislatures, and to strengthen their own testimony as expert witnesses,” Dr Cantor said.
One member said: “There are important lawsuits happening right now in the US, one or more of which could go to the Supreme Court, on whether trans care is medically necessary vs experimental or cosmetic. I cannot overstate the importance of SOC-8 getting this right at this important time.”
Another said: “I am concerned about language such as ‘insufficient evidence,’ ‘limited data,’ etc... I say this from the perspective of current legal challenges in the US. Groups in the US are trying to claim that gender-affirming interventions are experimental and should only be performed under research protocols.”
“[T]he systematic review on which WPATH based its standards for minors included exactly one study on puberty blockers and three studies on cross-sex hormones. All other references represent cherry-picked citations of studies rejected by its own systematic process. Moreover, even among the four studies in WPATH’s review, three were rejected by the Swedish review, due to the low quality of the science they contained.”—Clinical psychologist Dr James M Cantor, expert report in Alabama’s case, 19 May 2023
Fake news
One WPATH guideline group member was puzzled by the familiar but apparently false claim that the organisation’s standards of care enjoyed the endorsement of major medical societies, such as the American Medical Association and AAP.
“I have no idea how it was ever said that so many medical organisations have endorsed [WPATH’s previous guideline] SOC-7. This statement is made in many legal briefs and court proceedings,” the member said.
Some members took umbrage at pressure from junior AAP operatives to abandon minimum ages for surgery in SOC-8.
“This is really a shame if the experts at AAP are junior and flexing to change another societies (sic) guidelines,” one member said, with Dr Cantor noting that the author of AAP’s own 2018 affirmative policy, which misrepresented the evidence base, was a medical “resident still in training as a paediatrician at the time.”
Another member of WPATH’s guideline group remarked, “The AAP guidelines that [these junior people] mentioned so many times have a very weak methodology, written by [a] few friends who think the same.”
But Dr Cantor said an AAP threat to publicly campaign against SOC-8 if minimum ages7 were kept, combined with the pressure exerted via Dr Levine’s chief of staff, succeeded in stripping the WPATH guideline of minimum ages8 without any proper justification.
Screenshot: Coverage in The New York Times
“As Assistant Secretary of Health, I am urging us to base medical care on facts and medical evidence. Gender-affirming care is medical care. Gender-affirming care is mental health care. Gender-affirming care is literally suicide prevention care. It improves the quality of life, and it saves lives and it is based on decades of study. It is a well-established medical practice with new guidelines published by WPATH [in September 2022]. Gender-affirming care is medically necessary, safe and effective for transgender and non-binary youth and adults. Those who attack our LGBTQI+ community are driven by an agenda that has nothing to do with science and medicine.”—Dr Rachel Levine, speech, 13 June 2023
Science as a threat
In his commentary on internal WPATH documents, Dr Cantor seized upon a 12-point strategic plan devised to counter criticism following the chaotic 2022 publication of SOC-8 with minimum ages intact, followed by a “correction” doing away with them.
He said that plan made “some remarkable admissions”, such as, “Now that we have reviewed the evidence, we are painfully aware of the gaps in the literature and the kinds of research that are needed to support our recommendations.”
The plan also acknowledged that the shift away from gender medicalisation of minors in countries such as Sweden and Finland posed “a threat on our assertion that the WPATH SOC are the Gold Standard used around the world.”
Dr Cantor said the plan also contained “a list of adversaries and obstacles” seen as problematic for trans health care.
These included, in WPATH’s words, “academics and scientists who are naturally sceptical” and “continuing pressure in health care to provide evidence-based care.”
Dr Cantor said: “It is impossible to exaggerate the fatal importance of [this] categorisation of scientific scepticism and evidence-based medicine9 as a problem rather than the goal.
“An objective observer would perceive SOC-8 to be under attack from evidence-based care exactly because SOC-8 does not embody evidence-based care, although WPATH and other advocates of medicalised transition assert that it does.”
“… WPATH was possessed of extensive conflicts of interest throughout the production of Version 8 of its Standards of Care (SOC-8), while making false representations that it was complying with accepted conflict of interest principles for that process. WPATH’s financial well-being depends upon the number of its dues-paying members which, in turn, depends upon WPATH acting in its members’ financial interests: The more people who undergo transition, the greater the market available to WPATH’s dues-paying members.”—clinical psychologist Dr James M Cantor, supplemental expert report, 2 February 2024
More on WPATH
Journalist Jesse Singal’s news-breaking report of the Levine-WPATH nexus, Singal-Minded, June 2024
What The New York Times did not report, Reality’s Last Stand, June 2024
WPATH commissioned researchers to evaluate the evidence base for gender medicine, then blocked publication of unwanted results, medical watchdog group Do No Harm, May 2024
A citation cartel involving WPATH gives a misleading appearance of consensus favouring the gender-affirming model, Cass-commissioned research by the UK University of York, April 2024
WPATH is no model in the search for evidence-based care of transgender children, The Guardian, March 2024
Measuring “gender-affirming” guidelines against the standards of evidence-based medicine, British Medical Journal, February 2023
Dr Levine has promoted hormonal treatment as necessary for trans-identified children to avoid the “wrong puberty”—an intervention that may lead to their sterilisation and sexual dysfunction as adults—yet this trans woman is also on the record as saying that, “if I had transitioned when I was younger, then I wouldn’t have my children. I can’t imagine a life without my children.”
The political logic of doing away with minimum ages for surgery was not obvious to everyone. One WPATH member said: “I need someone to explain to me how taking out the ages will help in the fight against the conservative anti-trans agenda.”
The guideline development emails, or email excerpts, are published as an appendix to Dr Cantor’s report.
Half of America’s 50 states have passed laws prohibiting or restricting hormonal and surgical treatments for minors, and the nation’s highest tribunal, the Supreme Court, recently agreed to take an appeal to decide the validity of such laws.
On the supposed reversible nature of puberty blockers, Dr Cantor said in his report: “Although withdrawal of the medication will allow the pubertal process to resume, that is very far from establishing that the impact of that interruption of natural development is ‘fully reversible.’ The evidence is not that the person’s life will proceed as if the medical intervention never happened, as the popularised phrase suggests. Rather, the evidence repeatedly indicates that stopping a healthy child’s natural onset of puberty imposes multiple substantial harms, risks, or opportunity costs.” Also: “Because puberty blockers prevent prepubescent children from developing any understanding of sexual arousal and sexual relationships, such children are necessarily incapable of providing informed consent. There does not exist—indeed, there cannot exist—an age-appropriate way to equip a child who has not gone through puberty to make an informed decision about age-inappropriate issues, such as their future sex life, choices of sexual partners, sex-bonded relationships including marriage, and sacrificing ever experiencing orgasm.”
Dr Cantor’s 2019 “fact check” of the AAP policy remains unrebutted.
Dr Cantor said “age is the central component to young people’s emerging understanding of their sexual identities through social identity formation, pubertal development, and the onset of sexual interest.” And: “To understand medicalised transition of gender and its known and unknown consequences is one of the most complicated questions that a young person today could face, and a prepubescent brain [of a child on puberty blockers] is not equipped to process that information rationally, objectively, and with a whole lifetime rather than immediate desires and social pressures in mind.”
One minimum age remained; WPATH advised putting off phalloplasty—the fashioning of a pseudo-penis—until the age of 18. This procedure has an especially high rate of complications.
Dr Cantor said: “By allowing ‘consensus-based expert opinion’ to modify or overrule conclusions supported by systematic reviews that apply accepted criteria of evidentiary strength, WPATH has explicitly abandoned evidence-based medicine. As indicated already by the Pyramid of Evidence, ‘expert opinion’ represents the lowest level of evidence in science, whereas systematic review, the highest.”