No Minimum Age Requirements for Gender Surgeries

And other surprises of the new WPATH Standards of Care

Earlier this week, the World Professional Association of Transgender Health released the eighth version of its Standards of Care for the Health of Transgender and Gender Diverse People, which guide clinicians around the world in how to treat kids and adults with gender dysphoria, among other aims.

A separate chapter on treating adolescents—a first—had been much anticipated, especially amid not only ongoing culture wars and legal battles, but controversies over gender surgeries for kids. After advertising its gender surgeries for young people, Boston Children’s Hospital received intense criticism, and eventually a bomb threat—or a “hoax bomb threat”—and then claimed these surgeries weren’t happening at all. But there is ample evidence that, to quote WPATH, “breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery” for adolescents do happen.

When SOC8’s final document was first published, apparently to a select group, it had lowered the recommended ages for many of these surgeries.

Via Twitter

By Thursday, when the document was released to the public, WPATH had issued a correction, removing any minimum age requirements for medicines or gender surgeries. (Social transition may be recommended at any age). The story behind the correction is unknown, and many are concerned about it—what forces led to this kind of radical redacting?

A spokesperson from the Gender Exploratory Therapy Association (GETA) wrote to me that “GETA would like to know why a complex document years in the making was 'corrected' in such a significant way so soon after its release. What went into the abrupt decision to eliminate those minimum age requirements and how many and which of the SOC authors were involved in that decision?”

I can only speculate. This may have happened because of, as one psychiatry professor put it, “a concerted effort on the part of a group of trans authors on the soc8 to get rid of the arbitrary age requirements in the draft,” in favor of decisions that are “collaborative between care team and patient/family for minors.” That is, surgeries are decided based on Tanner stages and emotional readiness, determined by doctors and patients and families.

E. Kale Edmiston PhD 🧠 @EKaleEdmiston

@ButNotTheCity There was a concerted effort on the part of a group of trans authors on the soc8 to get rid of the arbitrary age requirements in the draft version. My understanding is that now the decision is collaborative between care team and patient/family for minors.

But they can happen, per this document, anytime. There are suggested criteria they could meet, including that their “Gender diversity/incongruence is marked and sustained over time.” But “sustained over time” is subjective, and in an earlier draft it had said “several years.” The child should meet the diagnostic criteria for gender dysphoria. The child should demonstrate “emotional and cognitive maturity required to provide informed consent/assent for the treatment,” but that’s also subjective. The child’s other mental health considerations should have been addressed, but that’s vague. The child should be informed about potential loss of fertility, but as we know from people like Corinna Cohn speaking up, an adolescent can’t always understand the lifelong implications of fertility loss—or impact on sexual function, which isn’t mentioned. And the child should have been on hormones for 12 months or longer… “unless hormone therapy is either not desired or is medically contraindicated.” So on hormones, or off hormones—either way.

The way these criteria are worded, and the loss of age requirement, seems to create a situation in which doctors can perform any surgical or medical interventions they want or think appropriate. Ultimately, they say, an “individualized approach to clinical care is considered both ethical and necessary.” Not all agree. Psychologist Leonore Tiefer wrote on Twitter, “what is the point of ‘standards of care’ if there are no standards?”

Why they removed the age requirements after publication of a document that WPATH authors had worked on for, per one source, five years is still a mystery. It may be a way to defer attention from the reality that surgeries are happening by not putting it in writing. It’s a protective shield of vague information that’s hard to combat. Perhaps it immunizes WPATH against criticism, forcing physicians to shoulder the burden.

Some trans activists and supporters of gender affirming care, who’d worked hard to deliver organized objections to the draft version, applauded WPATH for walking back some of the more cautious aspects of an earlier draft—that are seen by some as “gatekeeping.” Some were upset that comprehensive assessments are suggested, or that detransitioners were mentioned and considered.

Others jumped to the chapter on eunuchs and pronounced the whole thing insane.

Mia💚🤍💜 @_CryMiaRiver

WPATH released SOC8. I went straight for the Eunuch chapter. Just read this: "Like other gender diverse individuals, eunuch individuals may be aware of their identity in childhood or adolescence. Due to to lack of research into children who identify as eunuch..." THEY ARE INSANE.

But the adolescent chapter is clearly reaching for something resembling middle ground between those two camps. It acknowledges that parents need to be involved (as opposed to kept in the dark while schools secretly socially transition children). It notes that both demand and supply were rare until recently, when “there has been a sharp increase in the number of adolescents requesting gender care.” The supply is still too low, they write, so there are long waitlists and other barriers “for many transgender youth around the world.”

[How does one know that the adolescents requesting gender care are transgender? Early in the chapter they note that children eligible for medical transition had a “history of gender ‘non-conformity’/dysphoria,” as if those two things are interchangeable. But they’re not.]

They write that “gender diversity in youth should no longer be viewed as rare,” courtesy of the ballooning cohort of kids with non-binary identities, and a new group of adolescents with no history of gender dysphoria—or gender diversity. [Emphasis mine.] Most of those are girls, who sought care 2.5–7.1 times more than boys did. They acknowledge that for “a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider,” and that autism and other neurodivergence issues must be addressed.

Although detransition is still assumed by them to be rare, they write that “Some adolescents may regret the steps they have taken.” Sometimes a “young person will want to stop treatment and return to living in the birth-assigned gender role in the future.” [Emphasis mine.] Maybe that should even be discussed with kids before they transition, they surmise, and also, “providers should be prepared to support adolescents who detransition.”

Here they are acknowledging rapid-onset gender dysphoria, albeit without naming it, and the increasing phenomenon of detransition. These are the same issues that Sweden, Finland and the UK noted, which caused them all to radically alter their approach to treating young people with gender dysphoria. Those countries also all conducted systematic evidence reviews of the studies, and Sweden and Finland came to the same conclusion (the UK is still working out their shift): Risks outweighed benefits, and the quality of the evidence was so low that kids should only be medicated in extreme cases after long-term multidisciplinary treatment and evaluation.

But WPATH asserts that, because of the lack of long-term follow-up and the paltry amount and quality of research, “a systematic review regarding outcomes of treatment in adolescents is not possible.” This is not only not true, it makes them vulnerable to not meeting the criteria for standards of care.

Official standards of care “must be evidence-based, and not merely based on the evidence.” That is, you can’t just assemble the studies that align with your views and make recommendations. Rather, “Evidence-based standards of care must rest on the best available evidence that emerges from a concerted hypothesis-driven process of research synthesis and meta-analysis.” So without a systematic evidence review, it’s unclear if SOC8 should actually be considered standards of care.

WPATH’s presentation of the research is alarming to me as someone who’s been working hard to understand it for several years. They call puberty blockers “fully reversible,” but girls with precocious puberty who sued Lupron’s maker for permanent bodily damage would disagree, and so would trans-identifying kids with osteoporosis. They admit that “it is not possible to distinguish between those for whom gender identity may seem fixed from birth and those for whom gender identity development appears to be a developmental process.” They write that a “key challenge in adolescent transgender care is the quality of evidence evaluating the effectiveness of medically necessary gender-affirming medical and surgical treatments … over time. Given the lifelong implications of medical treatment and the young age at which treatments may be started, adolescents, their parents, and care providers should be informed about the nature of the evidence base.”

And yet, the chapter ultimately comes to this conclusion: “…early medical intervention—as part of broader combined assessment and treatment approaches focused on gender dysphoria and general well-being—can be effective and helpful for many transgender adolescents seeking these treatments.” The authors believe that it can be safe and effective to medically transition adolescents if they are properly and individually evaluated—not rushed to medicalize as some factions of “no gatekeeping” activists agitate for, and not all prevented from accessing these treatments. I’m not arguing with their assertion, but I am concerned that they looked at the same phenomena and evidence as other countries and came to very different deductions.

They note that “conclusions drawn from research cannot and should not be universally applied to all adolescents,” but also caution not to pay too much heed to the study on peer contagion and social media’s influence, because the research was conducted via a convenience sample, rather than a representative sample of the population, possibly skewing the outcome. But they only mention that criticism when they are presenting research that might upset people with strong ideological beliefs. Because that’s the same criticism of much of the research that says medical interventions improve mental health for kids with gender dysphoria, too. 

The reason they march forward toward affirmation anyway, WPATH says, is that they don’t want some kids to go through the wrong “irreversible puberty”—delaying until adulthood is not a neutral action. Once some of those secondary sex characteristics show up, it’s hard to avoid them. And it’s hard to pass as the opposite sex, should you want to transition later.

I think that was the case for some of the people involved in writing this chapter, and it’s an ongoing source of pain. They wish they had not been forced to wait, and perhaps they want to save others from that fate. But almost all the evidence we have reveals that such people are the minority of those with gender dysphoria, that the bulk of kids who experience this condition grow out of it. So should the SOC be geared toward the desisters or the persisters? Should only those who benefited from transition be consulted or do we need to hear from those who were harmed by it, or who didn’t transition and fared well (or poorly)? We don’t have long-term follow-up, we don’t know how many detransitioners there are, we don’t know how to tell persisters from desisters. Is having no minimum age for gender surgeries the appropriate response?

To the writers of this chapter, it’s important that those conducting the comprehensive evaluations—which they clearly believe in—don’t favor one outcome, that they don’t think it’s better not to be trans. But that’s never really been the question. The question is: what’s the safest and most effective way to treat gender dysphoria?

I don’t think anyone knows the answer yet.