An Alternative to WPATH's Guidelines

GETA's new guide

Photo by Pawel Czerwinski on Unsplash

What should a therapist—or doctor or teacher or parent—do when a young person with gender distress seeks their counsel? Until recently, the go-to resource for answers was the World Professional Association for Transgender Health’s “standards of care.” WPATH, a mix of medical and mental health professionals, students, activists, electrologists and others involved and interested in trans health care, has appointed itself the source of expertise, and much of the world has acquiesced, assuming it knows best.

For instance: In this episode of Dr. Phil, after evolutionary biologist Carole Hooven explains the research around sex differences, her opponent asks, “Has it been looked at by WPATH?” Teen Vogue tells its readers, “Doctors who provide gender-affirming services rely highly on standards set forth by the World Professional Association of Transgender Health.”

When their latest standards of care were released in September, many people, including me, were surprised by the inexpert way WPATH handled evidence, and by the recommendations they made—as well as the fact that the chapter on ethics had been removed, but the recommendations for the “gender identity” of eunuch had remained. They had abolished age minimums for surgeries, and while they made recommendations when it came to adolescents, most ended with a caveat: Parents should be involved… unless they’re not supportive. Adolescents should be on hormones for a year before surgery… unless they don’t want to. As one critique published in the BMJ noted, “It appears WPATH expects readers to faithfully accept potentially biased judgments of the literature rather than confidently submitting SoCv8 to open scientific scrutiny. SoCv8 could have been much better: its evidence base and recommendations cannot yet be relied upon.”

Problem was, there wasn’t much else to consult, until now. Last week, the Gender Exploratory Therapy Association released a Clinical Guide, an alternative to WPATH’s Standards of Care, “for psychotherapists, counselors, and clinicians who work with adolescents and young people from puberty to age 25.” But I think anyone with an interest in the history of the affirmative model could benefit from the research the guide contains. In fact, I think this guide will give journalists and others a good foundation in the research, the conflicts, and the concerns around this issue.

For example, here’s something that almost no one reporting on affirmative care seems to know:

The gender affirmative-approach is relatively new. It gained popularity after the publication of the “Dutch Studies” in 2011 and 2014. These two studies showed that high-functioning Dutch minors with an early-childhood onset of persistent and consistent gender dysphoria, who were medically transitioned after reaching mid-puberty, functioned well after their final surgery at the average age of 21. An attempt to replicate the successes reported by the Dutch researchers was undertaken at the world’s largest pediatric clinic in the UK, but failed to demonstrate the psychological improvements reported by the Dutch (Carmichael et al., 2021). There are also significant uncertainties about whether the findings of the Dutch studies are applicable to the current cohort of youth presenting with gender dysphoria.

The guide also outlines the physical risks associated with early transition that may be glossed over in some informed consent clinics, including “compromised bone density and brain development, cardiovascular complications, neoplasms, and other dangers.” But it acknowledges that in the short term, gender-affirming interventions can result in psychological improvement, without anyone knowing if or how long those benefits will last. That, combined with the ethical dilemmas early transition raises, suggests that “less invasive approaches, such as exploratory psychotherapy, should be the first line treatment for youth with gender distress.” This is what countries like Finland and Sweden suggest, too.

Some critics have conflated exploratory therapy with conversion therapy—a term that applies to largely condemned methods to change someone’s sexual orientation. But GETA has explained that exploratory therapy has no predetermined or single hoped-for consequence. Exploratory therapy, they assert:

• is open to a range of outcomes.

• understands that gender dysphoria emerges in a context.

• is developmentally informed.

• considers and addresses comorbid conditions.

• acknowledges the complex interplay of sexual development and gender identity.

• is a process that occurs over an extended time.

• maintains an evidence-based approach to suicidality.

• promotes true informed consent.

Hilary Cass, in her report for the NHS on the Tavistock’s GIDS clinic, outlined the problem of diagnostic overshadowing—not considering other mental health issues once gender dysphoria is acknowledged. Thus, it seems imperative for therapists to consider co-morbidities, and the interplay between gender dysphoria and other issues. That’s also why it’s so important to be honest and clear about the research on suicidality and gender dysphoria. Yes, this population has a higher rate of suicidal thoughts and perhaps even attempts; but they’re similar to rates in populations with other mental health diagnoses. And there is no good evidence that transition mitigates suicide risk—something every clinician working with this population should know. It seems to me this guide takes a common sense approach missing from WPATH’s guidelines.

The guide also makes explicit some points that may be hard for some in the pro-affirmation realm to digest, but which I think are important if we’re going to talk about how best to treat young people with gender dysphoria. Exploratory therapy “does not assume that trans identification is universally adaptive,” GETA writes. While many in the trans community have worked hard to depathologize being trans, and to assert that it’s not a mental illness, this guide acknowledges that in some cases, the assumption of a trans identity can be a maladaptive coping mechanism. “A trans identity can allow some people to flourish, providing greater freedom, autonomy and a sense of authenticity,” GETA writes. “However, for others it can be embraced as a solution to psychological pain, ultimately failing to provide the solution that was hoped for.” Thus, exploratory therapy “does not assume that gender-affirming interventions are universally helpful.”

Of note, the guide empowers therapists without specific training in gender issues to be able to work with youth experiencing them. Because gender exploratory therapy is, after all, therapy—and affirmation is not. “Exploratory therapy for gender dysphoria draws on the established principles of psychological engagement that most clinicians already utilize in their practices,” GETA writes. “Any clinician with training and experience in psychotherapy or counseling—who approaches their practice with careful exploration of the client’s unique personal experience, developmental history, and current life context—has the requisite skills to undertake work with young people with gender dysphoria.”

I still believe in the importance of expertise, but I believe that part of the reason kids with gender distress are receiving such poor healthcare is the rise of the gender affirmative industry, which silos those with gender dysphoria away from the general clinical population. The idea that one must claim an LGBTQ identity to administer care to a child who may or may not end up being part of that population—that’s related to the larger cultural privileging of “lived experience” over research, objectivity, and expertise. We see this in the own voices movement in literature, for instance: One must only write about one’s own identity and community. It’s also leaked into journalism: One must not report on a cohort to which one doesn’t belong; often you’ll see demands for only trans reporters to report on trans issues when an article is too nuanced. Subjectivity is preferable to objectivity.

This paradigm has overtaken healthcare, too, such that the lived experiences of patients seems to be outweighing the science. “Nothing about us without us” is a common saying among disability rights activists and in feminist healthcare. Perhaps you’ll recall the all-male panel making decisions about women’s healthcare from the Trump era (and, you know, most of American history). And, yes, the voices and experiences of those receiving these interventions should of course be factored into the guidelines.

The problem with “own voices,” is that it becomes “one voice.” It can lead to the idea that there’s a singular way of looking at a multifaceted story. And we always want to consider complex issues from multiple viewpoints, especially when it comes to mental health.

I’m curious to see what impact the guide has, if journalists start referring to it, if it’s picked up in academia, if GETA can truly be a contender to rival WPATH. One thing I do know: When our institutions fail us, new institutions will rise.