WPATH's Existential Crisis

A guest author examines the Big Story from another angle

‘I want to believe this will be the watershed moment, Andrew; really I do! I’m afraid I’ve become a bit jaded by all the cricket sounds that have followed revelations just as appalling as these. I’m managing expectations like it’s my job now, hoping to be proved wrong.’

—Me, in a comment on Andrew Doyle’s Substack earlier this week

For readers outside the rabbit hole, a brief news roundup is in order:

Genderland has been lit up all week by the release of ‘The WPATH Files’, an extensive dossier of screenshots and video conferencing accompanied by a detailed report of internal clinical discussions among ‘treatment professionals’ affiliated with the World Professional Association for Transgender Health. This event has been eagerly anticipated since Michael Shellenberger dangled its promise during his keynote address at the Genspect conference last November.

Shellenberger, a prominent journalist and author, had been given heaps of documentary evidence of clinical malpractice by a whistleblower inside WPATH, which would take his team several months to sort through and analyze. The big reveal finally dropped March fifth, to great fanfare—well, at least on Substack.

I have previously compared WPATH to the Ministry of Silly Walks, and I’ll do it once more. While the former is dangerous and malignant and the latter delightful and hilarious, I stand by the analogy’s utility because A) both are odd, unnecessary organizations, and therefore B) no one ever bothered to build an infrastructure to make them accountable: no Ministry of Regular Walks, no World Association for Human Sexual Dimorphism. That’s why WPATH has been loose in the wild for decades now, heeding nothing but its own increasingly deranged impulses, with endless funding provided by the world’s most indulgent autogynephiles.

As my note to Andrew Doyle suggests, I’m weary from the succession of explosive revelations, each one of which should have shuttered the joint once and for all. Yes, this one deserves nail-in-the-coffin status, but it’s not the first and I don’t expect it to be the last, so I couldn’t find the mojo to write about it.

Fortunately, the brilliant author of an earlier guest post emailed me his thoughts on all this and agreed to let me publish them here. He’s an academic researcher with grave concerns about the quality of research guiding ‘gender’ therapies, and his insight struck me as exactly right. I wish I’d written the essay that follows, but failing that, I’m thankful to have a smart friend who was willing to nail the homework and let me turn it in.

—JPA

---

Analysis by ML

There is a massive dichotomy between the two pieces of evidence in the WPATH Files. One shows the conversations on the organization’s forum discussing patients, where the discussion often veers into the ludicrous and the absurd. The other evidence is the video showing a leaked discussion (called the Identity Evolution Workshop) with a panel of six experts, which took place a few months before the release of WPATH’s Standards of Care Version 8 (SOC8).

In the video, what struck me was how closely the thoughts of these experts and the beleaguered parents align. Do I agree with everything they said? No.¹ However, there are several prominent points within the discussion where the parents would find themselves nodding with the experts. For example, the panelists state clearly that:

• Unlike other areas of medicine, so much is unknown when it comes to gender care

• Informed consent – as it exists today – simply does not work, either with young people or their parents

• Young people change their minds with regard to their identity – early and often

• In a society that is uncomfortable discussing and exploring one’s sexuality and yet discusses it in other ways that are not healthy, it is quite typical for young people to bury their discomfort about their sexuality and instead present their psychological distress in terms of their gender identity (which is more socially acceptable)

• As a result, the experts would want them to revisit their motivations, even if they have started their transition

• There is a need for prolonged psychotherapy to understand these motivations

• Often, what needs to change is their perception of their bodies rather than their perception of their identity

• Our healthcare system is woefully inadequate to treat these vulnerable people

• There are detransitioners – quite a few of them – and they need the same level of compassion and care as the people who transition

• The “community,” in their zeal to take away guardrails, harms both the doctors and the patients they want to care for

It is readily apparent how agonized these experts are as they wrestle with the concept of what proper care even means for the young population that has lately started to identify as transgender.

What is also apparent is how this discussion gets so much more fraught – and frankly does a disservice to the entire transgender community – thanks to the actions of the activists (whom the panelists refer to as the “community”), who have bullied the doctors to silence.

[It is this “community,” incidentally, that keeps repeating to the impressionable and vulnerable young people that medicalization is the only way forward and that without it, the only thing left for them is to commit suicide.]

During the panel discussion, the medical experts openly discuss how much they do not know.

It is very different, they say, to treat a known condition like diabetes with hormones – “there’s so much experience with that” – as compared to gender reassignment, where “this is all contentious.”

They also discussed the need for longer sessions with psychotherapists to understand what is going on in young people’s minds and the need for “a lot more caution,” especially if there are concurrent psychological comorbidities.

The panelists were very clear that informed consent, the way it is set up in the context of gender care, does not work. The patients do not have the knowledge of biology to understand the changes brought about by hormones – and neither do the parents, who often feel pressured to nod their heads in deference… “it really disturbs me when the parents can’t tell me what they need to know about a medical intervention that…they signed off for.”

Instead, over and over, the panelists say that informed consent is a journey – which can continue even after medical intervention has started. Patients should be asked how they feel right now during every meeting. It is okay to retrace steps if things are not working as they thought they would (“that door is still open”) or if they have changed their minds about what they want. Regret is real – and that is something that the patients internalize much later in their mid-20s when they are sterile and can’t have children with the “wonderful partner” they now have. But such a discussion does not make sense to young people:

“I'm going to adopt...And then you ask them, well, what does that involve?...[and they’re like] Oh, I thought you just like went to the orphanage and they gave you a baby.” Discussions about “gonads producing sperm or eggs that are going to be able to be usable if they want to be partners with somebody else later” seem such an alien concept.

The panelists repeatedly said that the young patients often have no idea about the changes the hormones will bring. Many patients imagined that they could pick and choose the effects they wanted. For some girls, all they might be looking for is not to have their periods. However, they do not want to grow facial hair, making a mockery of what they understood when they consented to when they were informed (as one panelist said, “You might not be binary, but hormones are binary, and so, you know, you can't get a deeper voice without probably a bit of a beard.”).

One gets a sense of futility and despair in trying to discuss informed consent properly with a young patient:

“It's like talking [about] diabetic complications with a 14-year-old. They don't care. They're going to live forever, right? When we're doing informed consent, that's a big lacuna – we try to talk about it, but most of the kids are nowhere in any kind of brain space to really talk about it in a serious way. That's always bothered me.”

They then added sarcastically, “But, you know, we still want the kids to be happy… happier… in the moment, right?”

The panelists discuss several cases where the patients changed their minds about their identity (“identities may shift and transition needs may shift”), which should inform the debate towards more exploration of one’s identity rather than fast-tracking a young person towards medicalization. In one case, six months after hormones, the patient (born male) who wanted to transition to a girl “reported that they felt more male and was feeling comfortable with he/him pronouns,” or, in his words, “I feel like a boy who wants to wear nail polish.”

Issues about one’s sexuality often get confused with one’s gender identity – “there’s a lot of ways that [gender and sexuality] intersect.” The panel discussed the case of a young patient who had undergone bullying and sexual trauma and initially identified themself as trans – “not an untypical story,” as a panelist put it, “just a kid working through crap” – and had started on hormones. Fortunately, after that “false start,” they received adequate psychological support and stopped identifying as trans, highlighting the importance of helping the young person “distinguish between the assault and their gender identity.” As a panelist pointed out, they have worked with patients where “their sexuality got to clarify some of their gender identity issues – maybe I'm not trans, maybe I'm nonbinary, maybe I'm cis, and maybe this was more of a sexuality issue.”

Sometimes, one panelist pointed out, it might not even be an assault but a sexually unpleasant experience that they went through when they were “trying to get themselves to learn about sex.” All such experiences can take a long time to come to terms with. However, the panel lamented the fact that discussing such psychological issues nowadays “can get a really bad rap” in “the community.” 

This case – and the case of the boy who wanted to wear nail polish – seemed to echo the concerns of the clinical psychologists at the NHS Tavistock clinic: therapists who once had months to work through underlying issues before making decisions on medical intervention were later making referrals for hormone therapy after just three-hour-long sessions, with the dark joke among staff that “there would be no gay people left.” Near the end of the discussion, one panelist spoke about some of their gay patients who historically avoided discussing their sexuality. (The same panelist had mentioned earlier, “I want people to feel like they don’t have to perform a certain gender to be working with me.”) There is a need to discuss their patients’ sexuality to “clarify some of their gender identity issues,” which they feel are vital to understanding a person’s identity.

“The thing that happens with sexuality is it gets framed as a negative – all the things we should not be doing… in a society that isn't very comfortable with [sexuality] in appropriate ways but is very comfortable with it in some ways that probably aren't very healthy.”

As a result, the panel implied, young people might present their psychological trauma around their sexuality in terms of gender identity, which is more acceptable [and perhaps even applauded] in society. It is essential, the panelists said, that patients today do not feel the need to come to a gender clinic and transition to hide their sexuality [something that happens in Iran, for example].

Transition also might not be the solution for every gender-dysphoric patient. One panelist, who identifies as a trans man, commented that “just because transitioning was right for me doesn't mean that it's right for somebody else” – a fitting riposte to people who think that any criticism of the indiscriminate handing out of hormones to minors is to pose shirtless to show the rest of the world that transition worked for them.

They wish they could ask questions about how the patients feel about their bodies, “regardless of your identity.”

“What's going to help you feel better about being in your body, and how do we address some of that? [Addressing that] might [sometimes] mean medical [interventions], that might mean lifting weights, that might mean eating better... There's a whole range [of possible changes one can undertake to resolve their gender dysphoria], but it just kind of shifts your thinking from identity-driven interventions to more... body-driven ones.”

At the same time, the young people are “so scared” [possibly primed to think that way because of what they read online?] that if they do not give the correct answers in the clinic, they won’t get the hormones – that is all they are fixated on. They might have decided on surgery, and while they are afraid of what it might mean, they are also “afraid to read” the details about the surgery. Sometimes, one panelist pointed out, because of their “binary” thinking, they can only think about the steps they must go through to transition (“I’m going to do this, then I’m going to do this, and then I’m going to do this”) without thinking about what those steps might mean. Unfortunately, the questions that should be asked at this point – “Who are you? What are you looking for?” – do not get asked.

The panelists also wish that the discussions were more reality-based: “Who is somebody you'd like to look like who [is] not… a TV star or… super attractive but just kind of an average-looking person so that we are not engaging in a fantasy realm of transition expectations?”

There is a need to have “deeper conversations” with the patient about what gender means to them and what it means in the broader sociocultural context, something that they need to get used to if they are to transition (one female panelist discussed what it might mean for a trans woman to being ignored as a woman – “things that feminists have been saying for a really long time,” while the panelist who identifies as a trans man discussed “losing… being automatically perceived as safe [as a female]”).

All such explorations take time – and maturity. Pointedly, one panelist described a “successful” case of an adult male who wants to identify as a woman: “Fortunately…this person is not in a rush and has found some ways to express their feminine side [while they contemplate their options]. The main point is that…I’ve seen this in adults, more mature adults, like 30-somethings.”

The panelists also discuss the inadequate system that hands out hormones and the need for multidisciplinary teams to advise young patients and their families. However, they point out, “Our healthcare system doesn't encourage this. Many people providing this care are independent practitioners, and they're referring their clients to surgeons…they may never have an endocrinologist [in their clinic]…[the patients] may be able to get their hormones prescribed through their primary care provider who doesn't really know necessarily everything about trans care. They're trying to be supportive, …and our health care system leaves us in the lurch all the time.” And yet, the system is such that they cannot talk about guardrails:

“We’re fighting against the community's desire to have less gatekeeping, less professional intrusion, less spending time in doctor's offices.”

As a result, young people are not only rushed into medicalization but are also denied psychotherapeutic support to reassess whether medicalization worked for them [the therapists who want to explore anything beyond blind affirmation are muzzled anyway].

“This is where…the detransition[ers] comes in…because of the over-medicalization and over-binarying…as well as the pressures that people are under because of the opposition [to gatekeeping] creates a dynamic that's very, very hard for all of us – trans people and clinicians – to work in.”

Could there be a more open admission about how the activists actively hinder the well-being of both the clinicians and the trans people they serve?

The panelists openly discussed the dangers of puberty blockers – “I'm sure putting a kid on a blocker at age nine, and then letting them get to the age when they're developing a sexual identity, can’t be great… I think we are robbing these kids of that early to mid-pubertal sexual stuff that's happening with their cisgender peers; their brains are just not thinking that way. They're getting older and smarter about [math], but they’re not learning how their body works. They're [not] learning how to masturbate because they don't have the urge to do that… And all of a sudden, they're way many years behind their peers trying to figure their sex stuff out.”

While the panel did not discuss detransitioners, one panelist had this to say about them near the end of the discussion:

“[I]t looks like a lot of folks are looking for support, and I would say we need to normalize their exploration just as we would normalize people considering transitioning to a gender different than what they were assigned at birth and to get them [the necessary] support to do that… and try not to marginalize… or put [them] down.”

Could there be a stronger statement of support for the detransitioners (and there’s “a lot” of them, even in 2022) or their healthcare rights?

---

1. For example, I disagreed with their philosophy of letting young people and even young adults – with their developing sense of “identity explorations” and their underdeveloped prefrontal cortex that drive executive functions – guide the medical professionals about their inchoate “embodiment goals,” even as they agree that these young people “do not have all the answers,” and some of the changes of medicalization are irreversible (they do mention that the young patients should start with drugs that are “affordable, cheap, safe, and reversible” – e.g., an anti-androgen like spironolactone – to keep their options open if they later change their minds).

I also thought that the panelists underplayed the lack of evidence of the benefits or risks of these largely unknown interventions. But I also realize these conversations took place a couple of years back. Only Finland had developed their guidelines (in 2020), and the UK had published the interim Cass reviews (2021). However, we were yet to see the slew of other systematic reviews that followed, for example, from Sweden (2023) and Germany (2024). Nor had Denmark (2023) published the extraordinary decrease in the number of referrals for medicalization between 2018 and 2022. And the WHO was yet to come out with a statement (2024) declaring that “the evidence base…is limited and variable regarding the longer-term outcomes of gender-affirming care for children and adolescents.”). At that time – May 2022 – the zeitgeist was probably that "something" needed to be done.