On the 15th of September, the World Professional Association for Transgender Health (Wpath) updated the Gold Standard of care for transgender and gender diverse (tgd) people. The Wpath guidelines essentially constitute a set of clinical guidelines, based on the best available scientific studies and professional expertise, with the purpose of educating and guiding health care professionals and programs, internationally. As such, they provide recommendations on both the most effective treatments and the most appropriate behaviors, as well as health care best practices (including linguistic and cultural aspects), to promote dignity and safety in approaching the health of tgd people.
Just one month after the publication of the new guidelines (SOC8), the chapter on adolescence has left behind (especially in the English-language media) a dust-up of alarmist invective, conspiracy theory and biased reporting. In some cases, even in professional and field publications such as the British Medical Journal. The most critical aspect is certainly the removal of precise minimum age recommendations in case it is indicated to provide medical and surgical gender affirmation treatments required by adolescents. It follows the recommendation to involve close relatives, "unless their involvement is determined to be harmful to the adolescent," thus contemplating the possibility of their exclusion from the evaluation and treatment framework. However, in hindsight, little or nothing has been reported about the rationale underlying these new recommendations. Still, SOC8 mark a significant step change in the approach to adolescent tgd health. Yet, to gain a better understanding of this shift, it is useful to set aside (for a moment) the context of public and political debate, and try to get a sense of Wpath's approach and thus its work in light of the state of research.
Who are tgd people and how many are there?
Gender identity is a concept that has relatively recently entered common usage. It comes from psychology and denotes "a person’s deeply felt, internal, intrinsic sense of their own gender," where ‘deeply’, ‘internal’ and ‘intrinsic' are not poeticizing adjectives, but rather define a constitutive element of any person's psyche. Gender incongruence or gender diversity occurs when a person develops a gender identity that differs from the gender assigned to that person, typically at birth based on observation of the external genitalia (to approximate, the ‘biological sex’).
It is still very difficult to estimate how often this phenomenon occurs worldwide. However, the data available are growing. While Western health providers report an average of 0.02 to 0.1 percent of the population, larger surveys range from 0.3 to 4.5 percent among adults to 2.5 to 8.4 percent among younger people. The growth in the data, as well as the leap between the percentages of adults and young people, should come as no surprise. In fact, it is only recently that large-scale systematic surveys have begun to be done, while at the same time both information as well as media visibility of tgd people and protective policies toward them have increased, fostering a phenomenon of emergence.
What are we talking about when we talk about their health?
Nowadays, gender incongruence is defined as a condition in the International Classification of Diseases and Related Health Problems (WHO, ICD-11). It is, therefore, not considered an inherently pathological phenomenon, which means that in itself it does not cause any harm to individuals. Yet, at the same time, gender incongruence is still stigmatized in many societies around the world-and sometimes denied in its scientific underpinnings, branded as "ideology" or "gender theory." This stigma can contribute to cases of abuse and violence. More than that, it often leads to the development of minority stress, in essence elevated levels of stress and psychological distress or even gender dysphoria - the latter is defined as a peculiar mental health condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and in this sense it is functional to the activation logics of most national health services. This set of socially induced symptoms typically have chronic valence and are statistically associated with significantly higher rates of depression, suicidal tendency, and self-harm than the average cisgender population (i.e., anyone who is not tgd). In all accounts, unable to ‘treat’ the phenomenon of stigma in human societies, health care for tgd people focuses on curative and preventive treatment of induced and related symptomatology through so-called "gender affirming" therapies. These mainly intervene on body aspects that heavily affect the psychosocial perception typically associated with stigma (consider genitalia, but also other socioculturally impactful aspects such as voice). Therefore, they may include hormone therapies and surgery. However, in some cases other much less invasive types of interventions are also sufficient.
Gender affirming therapies are called as such, as they support the gender identity developed by the tgd person. In this sense, they are diametrically opposed to "aversion" therapies, also known as "conversion therapies." Historically, the latter have long been tried-and in some contexts are still practiced-following the (unfounded) assumption of correcting or healing gender identity. In fact, from the earliest scientific studies in the second half of the 1800s until recent times, gender incongruence has been regarded as a mental illness or disorder in itself (often confusing it, by the way, with homosexual orientation, which was considered equally pathological). As a result, various therapeutic approaches have been developed for decades in the attempt to align gender identity incongruence with biological sex (sometimes even resorting to practices such as electroshock). Conversion approaches, however, have not only been found to be inconsistent in their scientific and diagnostic assumptions, but, when applied, have caused a significant increase in psychological problems in tgd people, correlated in turn by an increase in suicide cases. Therefore, both Wpath and leading international health agencies now condemn their use.
Wpath's new approach
The SOC8 come out ten years after the last update (SOC7), following an extensively documented elaboration and synthesis work to ensure transparency. The new guidelines are basically the result of a cross-comparison between analysis of new data and review of available scientific literature, as well as clinical experiences and circumstances. The author of this work was an international, multidisciplinary committee of about 120 members who are experts in various relevant fields, from health care to research, including a number of stakeholders. Finally, the Delphi methodwas used to draft the guidelines so that the committee's professional consensus was reached on each and every wording in the text.
The presence of stakeholders (about 13% of the committee) with experience in health advocacy in the so-called transgender community from different parts of the world is one of the methodological innovations. This was introduced to broaden the perspective on nonclinical factors influencing health decisions, both in appeal to the health principle of including patients' views on their own health issues and to ensure greater adaptability of the guidelines to different contexts globally. The latter aspect is particularly relevant. Indeed, the medical and scientific community has now recognized that the " expression of gender characteristics, including identities, that are not stereotypically associated with one’s sex assigned at birth is a common and a culturally diverse human phenomenon." However, most of the expertise, studies and scientific evidence regarding tgd people actually comes from the Western world. This has forced the committee to calibrate, as much as possible, the data and results of the studies. Also, to formulate the new guidelines in such a way as to reduce their possible friction with the variety of health policy realities worldwide. Consistent with this approach, one of the cardinal principles stated by SOC8 is the "flexibility" of the guidelines themselves. Hence, the explicit invitation to healthcare professionals and programs to modify them as necessary (by virtue of particular individual situations, lack of resources, need for specific harm reduction strategies, etc.) and in open communication, in order to promote healthcare best practice of informed decision-making.
So, what about the chapter on adolescence?
The creation of a chapter dedicated exclusively to adolescence responds mainly to three reasons 1) the exponential increase in the reference rates 2) the increase in studies on the subject of this population group 3) the peculiar issues regarding individual development in this age group. Scanning the specifics regarding these three aspects, one realizes both their actual relevance and the margins of uncertainty that still surround them, not the least of which is the fact that it is still unclear how gender identity develops psycho-physiologically. With good reason, Wpath itself strongly encourages further promotion of research on the subject.
Turning to the most controversial news, the previous guidelines diversified some minimum criteria according to the types of treatment: reversible, partially reversible, and irreversible. Grossly simplifying, for affirmative hormone treatments (estrogen or testosterone) parental consent was not required, but it was assumed that the adolescent had reached the legal age for health decisions, with reference to the 16 years of age valid in many countries (especially Western ones). For (almost) all surgical treatments, however, it was necessary to have reached the age of majority in one's own country. In the preliminary draft of the SOCs8 released in December 2021, another predefined time grid had initially been proposed, which already reduced the minimum age for different surgeries: at least 14 years for affirmative hormone treatment, 15 years for chest masculinization, 16 for facial surgery, etc. Exceptions were allowed in case of significant reasons in the treatment setting. The final text of SOC8, instead, eliminated the chronological grid altogether. The only two explicit time indications in the new “Statements of Recommendations” are that “the experience of gender diversity/incongruence is marked and sustained over time.” And in the case of surgery, that “the adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result.”
Though, the new text is much more prodigal in its exposition of specifics. The peculiarities of the adolescent period play a considerable role here. Indeed, it is not just the common perception that it is an age of great identity exploration, forward spurts and abrupt backward turns. Accordingly, the first specification states, “it is important to establish the young person has experienced several years of persistent gender diversity/incongruence prior to initiating less reversible treatments such as gender-affirming hormones or surgeries.” On the other hand, scientific studies attest that body development often proceeds in a manner that is staggered compared to cognitive, emotional and psycho-social development. In addition, individual paths differ widely: some people mature earlier and some mature later in the skills needed to confront such health decisions, regardless of their age at registry. Consistent with this, it is recommended that a case-specific, ongoing and gradual “comprehensive biopsychosocial assessment” be carried out, calibrating the progression in the provision of more or less reversible interventions from time to time, depending on the available evidence. The approach to adolescent tgd health changes, therefore, center of mass. The tool of a predefined time frame, poorly tailored to the reality of individuals, is greatly reduced, leaving more room (as well as responsibility) for case-by-case assessment by the relevant health professionals.
Regarding the, albeit legitimate, question of whether it would still not have been appropriate for the guidelines to at least set arbitrary age limits as a matter of prudence-as is done with, for example, driver's licensing or sexual consent-three considerations, namely of a bioethical, medical-clinical, and health-political nature, should be noted. The first is that “allowing irreversible puberty to progress in adolescents who experience gender incongruence is not a neutral act given that it may have immediate and lifelong harmful effects.” In this regard, recall what has already been said about the chronic valence of gender dysphoria associated with depression, suicidality and self-harm. The second consideration concerns finding the best approach to adapt the clinical framework. “For youth who have experienced a shorter duration of gender incongruence, social transition-related and other medical supports […] may also provide some relief as well as furnishing additional information to the clinical team regarding a young person’s broad gender care needs.” Although still few in statistical terms, the best available studies report extremely low rates of "detransition" (1.9-3.5 percent), i.e., disruption and reversal gender treatment. In addition, recent studies indicate that there are adolescents who choose the detransition, but still do not regret starting the treatment, as they experienced it as part of their understanding process. Finally, the last consideration concerns the global role of Wpath and the cardinal principle of flexibility mentioned earlier. The definition of age of majority, age of consent, or the age conditions regulating access to different health services can vary greatly from country to country. For example, within the United Kingdom the age of majority is 18 in England, Wales and Northern Ireland, however, it is 16 in Scotland; in other nations it is 21, as in Madagascar, and in others it even varies according to gender as in Iran: 9 years for women, 15 for men. Therefore, in the supranational perspective adopted by Wpath, establishing a predefined time grid a priori is not fruitful.
By the same token, it may also be easy to see the sense of contemplating parental exclusion from the treatment framework in case it may be detrimental to the adolescent. Based on studies, SOC8 recognize that “parent and family support of TGD youth is a primary predictor of youth well-being and is protective of the mental health of TGD youth.” Accordingly, their involvement in the assessment and treatment framework setting process is strongly encouraged, maintaining open and informed communication throughout the process. At the same time, by virtue of the social origin of health problems in tgd persons, in the case that the parental context is overly “rejecting,” the possibility is contemplated that “youth may require the engagement of larger systems of advocacy and support to move forward with the necessary support and care.” So, it is not recommended that health care professionals have the legal power to extinguish parental custody, so much as the possibility that, by the adolescent's request, the pertinent institutions can take charge of the adolescent's well-being.
In conclusion, in light of the new approach to health care centered on comprehensive biopsychosocial assessment on a case-by-case basis, it is worth noting that SOC8 provides 7 minimum requirements of different kinds (diagnostic, psycho-emotional assessment, informed consent, etc.) for the beginning of any treatment, even minimal, of gender affirmation to be recommended. In addition, there are 15 recommendations referring to the health care professionals themselves, especially regarding the kind of training and specialization needed, as well as procedures and health care best practices for proper evaluative and therapeutic approaches. Above all, this is what the Gold Standard of care for adolescent and tgd health consists of.
What's next?
All in all, no national health service is obliged to accept the new Wpath guidelines (several did not even do so with the previous ones, or only partially). Certainly, best practice in the medical-scientific field would suggest that a process of comparison, evaluation and updating be initiated at the international level by the WHO, at the level of national institutions, as well as competent health professionals-as indeed explicitly suggested by SOC8. The risk is that the chaotic and instrumental rehashing of the current public and political debate on tgd persons will end up radically contaminating this pathway. In the end, it would be (once again) the health of tgd people to pay the price. Right from adolescence.
