Sacrificial lambs

Jamie Reed spent 4½ years as a case manager at a pediatric gender clinic in St. Louis. She screened every new patient, took a medical history, and determined which clinicians the patient should see. “It gave me a wide, eagle-eye view of everything that was going on,” she recalled. And as she watched, the numbers started to shift. Reed noticed a rapid increase in the number of children and adolescents seeking transgender treatments, many of them teen girls with mental health problems and eating disorders. Medical providers diagnosed more than 42,000 children with gender dysphoria in 2021—nearly triple the number in 2017.  The St. Louis center—and roughly 100 other gender clinics that treat children and adolescents—look to the World Professional Association for Transgender Health’s Standards of Care to make decisions about patient treatment. Reed called the standards one of the center’s “guiding documents.”

At the time, Reed believed she was referencing well-researched clinical guidelines backed by strong medical evidence.

She didn’t realize “just how much had changed over the years with WPATH, and how many activists had really come into deciding how these standards of care were written.”

Nobody did.

That is, until the judge overseeing Boe v. Marshall—the legal challenge to Alabama’s law protecting gender-confused children and adolescents from hormones and surgery—ordered the release of internal communications between high-ranking WPATH leaders.

The unsealed deposition and discovery documents included bombshell revelations. Among them:

WPATH acknowledged major problems with the evidence underpinning its recommendation to treat children and adolescents with puberty blockers and cross-sex hormones.

But the organization kept those concerns quiet, even going so far as to suppress publication of research questioning its treatment regimen.

With little regard for scientific accuracy, the authors manipulated the standards’ wording to bolster the testimony of WPATH members serving as expert witnesses in courts across the United States.

Most notably, the organization removed age-limit recommendations from the chapter on adolescent treatment at the behest of a Biden administration official.

While WPATH told the world it crafted its clinical recommendations around the best available medical data, the authors actually had another underlying goal: to best their opponents in court. The trove of emails and comments on drafts of WPATH’s latest Standards of Care document provides snapshots of last-minute changes in response to political pressure, and fierce internal debates about how the wording of medical suggestions that allegedly stem from indisputable evidence would alter the legal landscape. Together, the documents chronicle WPATH’s downfall from a leading medical authority on gender dysphoria’s causes and cures to a special interest group pandering to an activist agenda.

WPATH BEGAN IN 1979 as the Harry Benjamin International Gender Dysphoria Association. It published its first Standards of Care, just a few pages long, shortly thereafter. In September 2022, the association published Standards of Care Version 8. The document, stretching to 258 pages divided into 18 chapters, is chock-full of recommendations for healthcare providers treating adults, adolescents, and children.

Today, as many as 271 gender clinics across the United States look to the organization’s guidelines.

At the time of the association’s founding, only one person who identified as transgender sat on the board, which was predominantly composed of doctors and mental healthcare providers.

But over the years, the organization’s composition shifted. Today, many of these educators, lawyers, doctors, and psychotherapists identify as transgender, according to a former WPATH member who served as a faculty member for WPATH’s Global Education Institute and sat on important committees. (WORLD agreed not to name the member, who also identifies as transgender, due to concerns about retaliation.)

Court documents show WPATH’s growing activist wing viewed the Standards of Care less as a document meant to be read and discussed among professionals than as an advocacy tool meant to help trans people access care. These activists slowly chipped away at the standards’ safeguards, accusing WPATH of “gatekeeping,” a term activists hurl at healthcare providers who mandate waiting periods or mental health assessments before providing medical interventions.

In one of the unsealed email exchanges, WPATH leaders acknowledged the role activists played in revising its most recent standards. “There has been a great deal of pressure placed on that chapter and on the editors by a wing of the community who want to have everything done on demand or it is otherwise transphobic or denying autonomy,” Madeline Deutsch, the former president of the United States’ branch of WPATH (USPATH), admitted.

Case in point: Standards of Care Version 7 recommended a patient seeking any type of gender surgery first undergo at least 12 months of hormone therapy and live full time as the desired gender for the same amount of time, in what’s referred to as a real-life test. Standards of Care 8 lowered the hormone suggestion to six months and did away with the real-life test.

“These kind of safeguardings erode and erode and erode,” said Reed, the former case manager at the St. Louis gender clinic. “It doesn’t surprise me that we end up where we are today, which is this huge number of people seeking to medically transition, and now … a large number of people who are saying, I did this, and it was not the right thing for me.”

Between 2017 and 2021, medical providers diagnosed 121,882 U.S. children ages 6 to 17 with gender dysphoria. At least 17,683 of those children with a prior gender dysphoria diagnosis started on puberty blockers during that five-year period. But that’s likely an undercount since it doesn’t include treatment not covered by insurance or those who receive treatment but don’t have an official diagnosis. A growing number of individuals, known as detransitioners, regret their decision and face a lifetime with the lasting scars of irreversible medical procedures.

St. Louis Children’s Hospital, where the youth gender clinic is located Bryan Birks/The New York Times/Redux

ANOTHER BIG CHANGE in the new standards of care document involved age limits for children seeking to change their gender. The previous version recommended minimum age requirements: 16 before a patient begins using cross-sex hormones and 18 before an adolescent undergoes genital surgery. Version 8 originally lowered those limits, and then deleted them altogether. But not because of any new medical evidence.

Emails between WPATH leaders reveal Rachel Levine, the assistant secretary for health at the Department of Health and Human Services, pressured the organization to remove the age-limit recommendations from the chapter on adolescent treatment.

Levine, born Richard Leland Levine, is the highest-ranking Biden administration official to openly identify as transgender. Sarah Boateng, Levine’s chief of staff at the time, reached out to WPATH leaders in July 2022, two months before they published the Standards of Care. “She is confident, based on the rhetoric she is hearing in DC, and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care. She wonders if the specific ages can be taken out,” a WPATH leader wrote in an email to the co-chairs of the committee drafting the standards of care and the adolescent chapter lead authors.

Levine’s last-minute request to remove the age limits wasn’t the first time the Biden administration official had meddled in WPATH’s supposedly independent, scientific process. Joshua Safer, one of the Standards of Care authors and a former USPATH president, spoke with the assistant secretary in August 2021. “I just got off a very productive call with Rachel Levine. The failure of WPATH to be ready with [Standards of Care 8] is proving a barrier to optimal policy progress,” he told four of his colleagues in an email.

“My view is that this should be taken as a charge from the United States government to do what is required to complete the project immediately.”

As the WPATH chapter committees worked to revise the Standards of Care, a growing number of states enacted bans on performing transgender surgeries on minors and prohibited doctors from prescribing them puberty blockers or cross-sex hormones, based in part on evidence that emerged in Europe warning of lasting harm. Arkansas adopted the first law prohibiting transgender procedures on minors in April 2021, four months before Safer spoke with Levine. Twenty-five states followed suit. Tennessee’s protective measure is headed to the Supreme Court this fall.

It was against this policy backdrop that Levine requested the 11th-hour change. “[Levine] was very concerned that having ages (mainly for surgery) will affect access to healthcare for trans youth and maybe adults too,” a WPATH leader wrote to the group drafting the adolescent chapter. “Apparently the situation in the USA is terrible and [Levine] and the Biden administration worried that having ages in the document will make matters worse.”

At first, some WPATH members recoiled at the thought of making such a major change to the adolescent chapter after it had already passed the Delphi process, a research method used to find consensus among a group of experts while reducing the risk that peer pressure influences the outcome. “I don’t know how I feel about allowing U.S. politics to dictate international professional clinical guidelines that went through delphi,” one committee member wrote.

Another chimed in: “If our concern is with legislation (which I don’t think it should be—we should be basing this on science and expert consensus if we’re being ethical) wouldn’t including the ages be helpful?”

But the pressure kept building. After Levine requested the organization remove the ages, the American Academy of Pediatrics (AAP) also demanded WPATH delete the adolescent age limits since they did not align with AAP’s own guidelines. The group warned it would publicly oppose WPATH’s updated standards of care if the age limits stayed in place.

WPATH ceded defeat.

Since the organization had already released a text of the draft for public comment, WPATH leaders scrambled to create a scientific-sounding explanation for the rather noticeable edit in the final version. Leaders told reporters they removed the age limits due to “a great deal of input” received during the open comment period and wanted to emphasize individualized patient care rather than “superficial evaluations.”

In a September 2022 email, a WPATH member applauded the smooth explanation: “Exactly—individualized care is the best care—that’s a positive message and a strong rationale for the age change.”

Only, that had nothing to do with it.

Department of Health and Human Services Assistant Secretary for Health, Adm. Rachel Levine Associated Press/Photo by Mark Schiefelbein

THE RECENTLY DISCLOSED communications reveal committee members agonized over the lack of evidence to back up their recommendations—especially those dealing with children and adolescents—and recognized their shaky scientific basis would hurt trans advocates in court.

In August 2022, one month before the standards’ release, Eli Coleman, who chaired the committee authoring Standards of Care 8, urged the adolescent chapter co-chairs to prepare a “more detailed defense that we can use to respond to academic critics and that can be used in the many court cases that will be coming up that will try to restrict access to [transgender] care—especially around adolescence.” Coleman acknowledged some of the studies cited in the chapter would be “torn about” by critics.

Jeffrey Barrows, senior vice president of bioethics and public policy at the Christian Medical & Dental Associations, noted most of the studies related to transgender care for adolescents are observational, not investigative.

“They have been small. They are highly susceptible to bias by the authors,” he said.

Barrow pointed to Dr. Hillary Cass’ report, a four-year review of the evidence for transgender procedures on minors conducted at the request of the United Kingdom’s National Health Service. It determined much of the evidence cited to support these procedures is poor.

WPATH commissioned a Johns Hopkins University research team to conduct systematic reviews of the available research to ensure Standards of Care 8 was backed up by the latest available research. When it became clear the researchers found little to no substantial evidence to support the organization’s recommendations for adolescents, WPATH leaders tried to keep the team from publishing its findings, emails show.

Members put on a unified front in public. But in private they had fierce debates about the consequences of putting young children on puberty blockers and whether or not to lower the suggested time a patient should remain on cross-sex hormones before undergoing surgery. Other email chains show leaders admitting social contagion could play a role in the increasing number of teenagers, mainly adolescent girls, seeking treatment. But once again, WPATH leaders kept such concerns to themselves, even censuring researchers who dared explore the theory.

COMMITTEE MEMBERS also tailored the wording of their recommendations to strengthen the testimony of WPATH members serving as expert witnesses in courts around the country—even if it wasn’t scientifically accurate—and failed to disclose these direct conflicts of interest.

For instance, one committee member, whose name is redacted in the court documents, raised concerns about using language such as “insufficient evidence” and “limited data.”

“I say this from the perspective of current legal challenges in the U.S. Groups in the U.S. are trying to claim that gender-­affirming interventions are experimental and should only be performed under research protocols (this is based on two recent federal cases in which I am an expert witness).”

In another email exchange, members debated the use of the word “estimate” and how a judge might consider its meaning in court. “Judges and law-makers will dismiss estimates in a way in which they will not research,” one member argued. “My hope with [Standards of Care 8] is that they land in such a way as to have serious effect in the law and policy settings that have affected us so much recently; even if the wording isn’t quite correct for people who have the background you and I have.”

“The emails show intentional tinkering with the language,” said Roger Brooks, an attorney with Alliance Defending Freedom who joined the Alabama attorney general’s office to help defend the state’s law. “It has been tailored for courtroom advantage instead of scientific accuracy.”

Brooks deposed Eli Coleman, the Standards of Care 8 committee chair, as well as Marci Bowers, the current president of WPATH. Though the transcripts of these depositions are not yet publicly available, Brooks said the depositions validated the document’s bombshells, particularly the late-stage text changes to gain advantage in court.

WPATH leaders zeroed in on the language of medical necessity—an essential phrase for trans advocacy groups challenging state bans—as they drafted the standards. The internal correspondence between members shows these lawsuits took center stage in their choice of wording. “There are important lawsuits happening right now in the U.S., one or more of which could go to the Supreme Court, on whether trans care is medically necessary vs experimental or cosmetic. I cannot overstate the importance of [Standards of Care 8] getting this right at this important time,” one member wrote.

The final version of Standards of Care 8 included the following statement: “We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.” In total, the document used the phrase “medically necessary” 23 times.

In an email exchange debating the exact wording of the statement, one member explicitly referred to such language as a “tool for our attorneys to use in defending access to care.” The individual continued: “I have long wanted this (and many of our other policy statements) to become part of the [Standards of Care] because that gives them greater force.”

Emails appear to indicate that WPATH went so far as to send the Standards of Care for legal review before publication, to ensure the wording would not hinder trans advocacy groups challenging state bans.

Walter Bouman, a member of the Standards of Care committee who co-led the Working Group on Non-binary Genders, voiced his concerns about subjecting the guidelines to legal scrutiny in an email to other WPATH leaders, noting that no other respected clinical guidelines undergo a legal review. “The SOC8 are clinical guidelines, based on clinical consensus and the latest evidence based medicine; I don’t recall the Endocrine Guidelines going through legal reviews before publication,” he wrote in August 2021.

But Jamison Green, a former WPATH president, argued a legal review was essential in light of the U.S. legal landscape. “We should at least be aware of any conflicts in that area, even if the [Standards of Care] content doesn’t change to accommodate it,” he noted. “Because we will have to argue it in court at some point.”

Jamie Reed Photo by Sean McRae Loftin/Genesis

JAMIE REED WENT PUBLIC with her concerns about the St. Louis gender clinic’s practices in February 2023, appalled at how quickly providers referred children for hormone prescriptions with irreversible effects. Today she heads the LGBT Courage Coalition, a group of whistleblowers and adults who identify as gay, trans, or bisexual and advocate for a national moratorium on transgender procedures for children and adolescents. Reed also is married to a woman who lived as a man for 13 years but recently announced plans to detransition.

The window into WPATH’s unsealed communications—which Reed described as validating and “absolutely frustrating”—revealed high-ranking WPATH officials responsible for crafting clinical guidelines shared her concerns, and acknowledged the science is far from settled.

“I think the legitimacy of this document has just been completely blown out of the water,” Reed argued. “If you are going to pull the age guidelines in a pediatric element at the 11th hour, because a trans government official tells you to, I just have zero confidence in any of the rest of the document. … It should not be being used in a general medical setting.”

Her coalition is gearing up for a Supreme Court decision in United States v. Skermetti, the legal challenge to Tennessee’s law protecting minors from transgender procedures. If the court sides with Tennessee , “that will leave us, then, in the United States with a pretty evenly split map,” Reed said, adding that makes public education campaigns like hers even more essential.

“This is not a red-blue issue. This does not mean Republicans coming after the glitter kids. This is actually a question of medical care and scientific evidence, and are we harming a vast number of children?”