Leading Transgender Health Association Releases New Guidelines

 The leading transgender health association has released its much-anticipated new guidelines. One aspect noticeably different from previous editions is that the explicitly stated minimal age recommendations for minors to obtain puberty blockers, cross-sex hormones, and surgeries have been removed.

The new guidance also suggests that if parents do not affirm their child’s newly chosen identity, the state may be enabled to intervene in order to assist with the child’s transition.

The World Professional Association for Transgender Health (WPATH) published its Standards of Care 8th Edition in International Journal of Transgender Health on September 6, 2022. A correction was published in the same journal on September 15, which removed sections pertaining to “minimal ages for gender-affirming medical and surgical treatment for adolescents.”

WPATH guidelines are considered the gold standard for the field of health care for those diagnosed with gender dysphoria, and are widely used in hospitals and clinics across the U.S., Canada, and the U.K. WPATH guidelines are highly influential to major medical groups, including the American Academy of Pediatrics and the American Psychological Association, as well as for health insurance companies around the world.

A confidential draft of the 8th Edition was released for public review in December 2021 that lowered the recommended minimum age for minors to obtain cross-sex hormones — which cause permanent changes to the body — from 16 to 14, and irreversible chest, face, and genital surgeries to 15, 16, and 17, respectively. Little has changed from the early draft, and while WPATH no longer provides explicit minimum age recommendations in their latest official guidelines, a close reading finds that age suggestions for some procedures are woven into the text.

Chapter 6 on adolescents in the new guidelines suggests that cross-sex hormones may be administered to children as young as 14. “More recent guidelines suggest there may be compelling reasons to initiate [gender affirming hormone therapy] prior to the age of 16, although there are limited studies on youth who have initiated hormones prior to 14 years of age.” However, these are only guidelines, and not hard rules that must be followed.

In the same chapter, guidance is issued for “chest masculinization surgery,” otherwise known as a double mastectomy, which is the removal of healthy breasts. “Chest masculinization surgery can be considered in minors when clinically and developmentally appropriate as determined by a multidisciplinary team experienced in adolescent and gender development.” Though no precise age is indicated, most pediatric gender clinics will perform double mastectomy surgeries on 15 year olds.

Guidance on vaginoplasties, the creation of a pseudovagina using existing genital tissue, indicates they may be obtained as a minor. “While the sample sizes are small, these studies suggest there may be a benefit for some adolescents to having these procedures performed before the age of 18,” reads the guidelines.

WPATH also indicates that vaginoplasty is often performed on minors, citing a 2017 study. “A 2017 study of 20 WPATH-affiliated surgeons in the US reported slightly more than half had performed vaginoplasty in minors.”

The only genital surgery it seems the WPATH is comfortable setting an age recommendation for is phalloplasty, which creates a penis-like phallus from skin grafts taken elsewhere on the body. “Given the complexity of phalloplasty, and current high rates of complications in comparison to other gender-affirming surgical treatments, it is not recommended this surgery be considered in youth under 18 at this time.” But again, these are only recommendations.

WPATH’s new guidance also suggests that parental consent for minors to obtain medical treatments are recommended, but not required, and that state powers may intervene if a parent does not affirm their child’s chosen identity.

“6.11- We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.” (emphasis added).

Statement 6.11 in Chapter 6 on adolescents further elaborates: “Helping youth and parent(s)/caregiver(s) work together on important gender care decisions is a primary goal. However, in some cases, parent(s)/caregiver(s) may be too rejecting of their adolescent child and their child’s gender needs to be part of the clinical evaluation process. In these situations, youth may require the engagement of larger systems of advocacy and support to move forward with the necessary support and care (Dubin et al., 2020).” (emphasis added).

In the Appendix is a “Summary Criteria for Adolescents” that further demonstrates that parents should be involved unless their involvement is deemed “harmful” or “not feasible” to their child’s medical transition. “Involvement of parent(s)/guardian(s) in the assessment process, unless their involvement is determined to be harmful to the adolescent or not feasible.”

The “Summary Criteria for Adolescents” continues without minimal age recommendations. Instead, WPATH suggests that both puberty blockers and cross-sex hormones may be administered when a child reaches Tanner Stage 2, meaning at the first signs of puberty. For girls, puberty begins between ages 9-11, and for boys around age 11.

For surgeries, no indication of a minimal age is given in the guidelines, and instead it recommends: “At least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.”

Notably, in place of minimal age recommendations for puberty blockers, cross-sex hormones, and surgeries, the adolescent criteria states: “Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.” Chapter 6 on adolescents elaborates on their meaning of cognitive maturity. “The ability to reason hypothetical situations enables a young person to conceptualize implications regarding a particular decision.”

The Society for Evidence Based Gender Medicine (SEGM), an international group of over 100 clinicians and researchers, responded to the 8th Edition early draft in a critique in January 2022, citing the potential for harm due to their lack of methodological rigor and very low-quality evidence.

WPATH says that their guidelines were written “based on available evidence,” but cite flawed, cherry-picked studies to support their conclusions. “The current description of the literature betrays a strong bias toward studies promoting social and medical transition,” said SEGM.

WPATH’s annual conference in Montreal begins on September 16 and ends September 20.