WHO Should Go Back to the Drawing Board on its Transgender Health Guidelines

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WHO Should Go Back to the Drawing Board

We call on the World Health Organization (WHO) to participate in, rather than preempt, an open and transparent dialogue about the scientific and societal implications of gender dysphoria treatments, the importance of biological sex, and the best way to protect trans-identified individuals without sacrificing protections for other vulnerable groups including women and children. Such a dialogue requires that a diversity of perspectives from experts and stakeholders be heard, that the public be given sufficient time to weigh in, and that the guideline development group (GDG) take the time and care necessary to understand all the risks, benefits, and unknowns involved, rather than arriving in Geneva with their minds already made up.

On December 18, 2023, WHO announced that it will be developing a guideline on "the health of trans and gender diverse people." WHO also published the names of the 21 guideline panel members who are scheduled to meet from February 19-21, 2024 at WHO's headquarters in Geneva, Switzerland. As part of that announcement, WHO opened a brief window for public comment, scheduled to close on January 8, 2024.

The signatories to this online Petition have many grave concerns about WHO's announcement. These concerns, addressed in greater detail below, include:

Biased guideline development group (GDG). The current panel is highly biased in favor of "gender-affirming" approaches, with an absence of critical perspectives. The majority of the panel members have expressed strong views in favor of hormonal and surgical interventions for transition, dismissed known and potential risks associated with these interventions, and denigrated psychotherapeutic approaches as "conversion therapy". The panel does not include any experts in child and adolescent development or any critics of the affirmation model. Detransitioners and desisters are also excluded. Given the panel's composition, there is strong reason to believe that the guideline will be similarly biased.
Perfunctory public consultation period. WHO opened a brief window (just three weeks) for public comment at a time of year when much of the world has unplugged to celebrate the holidays. This suggests a lack of interest in gathering the public's input.
Rushed guideline development process overall. The group's meeting to make key decisions has already been scheduled for February 19, 2024. This does not provide sufficient time to create a balanced panel, commission independent reviews, and synthesize the evidence - let alone issue responsible recommendations.

A. Biased panel composition.

A cursory internet search into the positions and views held by the 21 guideline panel members finds that most have denigrated exploratory therapy as “conversion therapy" while promoting a highly medicalized “gender-affirming” approach. Three-fourths of these members are either trans-identifying individuals, members of advocacy organizations like Global Action for Trans Equality (GATE), or members of the World Professional Association for Transgender Health (WPATH), including multiple former WPATH presidents and executive commmittee members supportive of that organization's medicalized approach to managing gender dysphoria in adolescents and young adults.

Some members have failed to properly disclose conflicts of interest in their publicly shared profiles. For example, Teddy Cook served as Vice President of AusPath - a fact not mentioned in his biography contained within WHO's announcement. We also note with concern that WPATH endorses the so-called "informed consent" model of care requiring no psychological assessment whatsoever, and in its most recent Standards of Care (SOC-8) removed nearly all age restrictions for hormones and surgeries while promoting the unevidenced view that minors can identify as "eunuchs".

Given the highly polarized nature of gender medicine, conflicts of interest (COIs) are unavoidable, especially regarding intellectual positions held. However, WHO has a responsibility to fully disclose and balance such conflicts among members to ensure they produce unbiased guidelines. There should be as many pro-affirmation individuals on the GDG as there are members concerned about its potential harms. There should be a diversity of stakeholders, not just in terms of geographic location (which WHO did achieve) but also regarding their professional backgrounds and perspectives.

We wish to express our deep concern regarding the care of gender-questioning children, adolescents, and adults. Important questions remain unanswered, concerns regarding risks and unknowns are mounting, and the science is far from settled. The explosion of adolescents and young adults identifying as transgender and seeking life-altering interventions (and the concurrent shift in patient demographics) is poorly understood. These young patients are overwhelmingly female, typically have no history of childhood gender dysphoria, and often present with serious neurocognitive and psychiatric comorbidities. Rising numbers of detransitioners show that medical practice in this area is flawed and that some patients are being harmed rather than helped. Any guideline recommendations made by WHO must therefore address the needs of this complex and vulnerable group. The GDG as constituted, however, does not include a single detransitioner, desister, or expert working with these cohorts.

While a biased WHO guideline is likely to have little impact on countries with strong public health authorities already adhering to the principles of evidence-based medicine (e.g., England, Finland, Sweden), it will have a detrimental effect on other countries where the debate is just emerging (e.g., Australia, Germany, the United States). In addition, it will likely have a negative influence on public health in developing countries that do not have the resources or expertise to invest in a quality guideline development process, and who have come to rely on WHO guidance for defining and promoting best practices.

B. Brief and perfunctory public consultation period.

WHO provided a very short window for public comment (Dec 18th-Jan 8th) which falls over the winter holidays. During this period, most people are unable to engage with detailed documents and write responses. This is the second instance of WHO creating such a short window for response during a holiday period. The first time, when the original announcement was made in June 2023, coincided with a common summer holiday break and allowed a mere two weeks for public comment. The list of panelists WHO shared at that time was incomplete.

We are also concerned that WHO has already scheduled the panel group's meeting in Geneva in mid-February 2024 when the group will be tasked with making a number of important decisions and recommendations. This would seem to render the public comment period moot, for WHO would be unable to address public concerns about the panel's composition in such a brief timeframe.

This meeting must be postponed until the public has been given ample time to review and comment on the composition of the GDG and its charge to develop recommendations around hormonal and surgical interventions, as well as legal gender self-identification. WHO must address the conflicts of interest that are already apparent by rebalancing the panel's membership. Some members should not be allowed to participate due to extreme intellectual conflicts of interest (which the WHO handbook specifically calls out), while other members' participation may need to be confined to certain areas. In addition, WHO should consider hiring an independent methodologist to assist in the guideline development process.

C. Rushed guideline development process.

The final composition of the panel was only announced on December 18 but, according to WHO, this group will evaluate the evidence and formulate recommendations across a range of topics including healthcare, clinician education, health policies, and laws by February 21. To call this a rushed procedure would be a dramatic understatement. Compare this to the process embarked upon by the Cass Review in the UK, for example - a multi-year effort to address the health care needs of just one patient demographic (under 18s) within a single country (England).

This is lightning-fast speed for any organization, but especially for WHO, which must consult with various stakeholders, commission evidence reviews from third parties, and potentially engage independent experts to help oversee the guideline development process. None of this can be realistically accomplished within WHO's artificially constrained time frame.

* * *

For all the above reasons, the signatories to this Petition call on WHO to appoint individuals with a range of perspectives to the guideline development group and extend the period for public comment to ensure that all voices in this debate have an opportunity to be heard. We request that WHO cancel the upcoming February Geneva meeting for the guideline development group as currently constituted, and address the many conflicts of interest currently in play. We also ask for transparency regarding how participants in the GDG are selected, full disclosure of any conflicts of interest (financial as well as intellectual), and a clear plan for how WHO intends to balance strong opposing views and facilitate dialogue across differences of perspective.

Members must also represent a range of perspectives on the important question of legal recognition of gender self-identification. These issues have profound implications for both trans-identified individuals and society-at-large (particularly the rights of women and girls), and must not be rushed.

Finally, we request that WHO observe its own internal procedures for the development of guidelines, to ensure that such guidelines are trustworthy and credible. All WHO guidelines must rely on the best available evidence. Where evidence is weak, as it is in this area of medicine, guidance must clarify risks and unknowns. If recommendations are made, WHO must make clear whose values and preferences are driving the recommendations and specify what those values are. This is a requirement for any evidence-based guideline.

Deploying the language of evidence-based medicine without actually practicing it is not enough. Gender-dysphoric and gender-questioning patients of all ages deserve better; the unique needs of children, adolescents, and young adults demand particular care and attention -- as do women's rights to safety.

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WHO Should Go Back to the Drawing Board on its Transgender Health Guidelines

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