The WHO’s Stealth Campaign to Avoid Public Scrutiny on New Gender Guidelines

The WHO’s guideline development group on gender medicine is ideologically biased and the hurried nature of this process appears intentionally designed to minimize public input.

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About the Author

justdad7

is the Twitter handle of a retired Canadian lawyer with an interest in human rights and medical ethics issues. He publishes a Substack newsletter and has contributed to various briefs to Canadian legislature and the Genspect Canadian school policy document.

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The development process of the World Health Organization’s guideline on the health of trans and gender diverse individuals represents a significant missed opportunity. There’s a clear need for a reliable international guideline, especially considering the increasing global scrutiny of the affirming care model endorsed by the World Professional Association for Transgender Health (WPATH). In several countries, notably the United States, this debate has become entangled in partisan politics. Ideally, an international organization like the WHO would help steer this debate towards evidence-based medicine.

However, WHO’s approach to developing this guideline reveals a concerning disregard for the principles of evidence-based guideline development, a problem that is particularly acute in gender medicine. The final membership of the WHO’s guideline development group was announced on December 18, 2023, with public comment open until January 8, 2024. The group is scheduled to meet from February 19 to 21, 2024. The hurried nature of this process appears intentionally designed to minimize public input. Even more concerning is the clear bias in the group’s composition that favors the medical model of “gender-affirming care.”

Clinical guidelines aim to help clinicians navigate the vast amount of research on different treatments, enabling them to make decisions based on the best available evidence. Managing conflicts of interest is a critical aspect of developing these guidelines. Medical professionals, despite their best intentions, can develop biases toward specific treatment types. This bias can lead to a preference for studies that support their favored care model and a dismissal of contradictory evidence.

Internationally recognized standards exist for the development of trustworthy medical guidelines, and the WHO has incorporated these into its Handbook for Guideline Development. Chapter 6 of this handbook specifically addresses the management of conflicts of interest and outlines potential sources of conflict. Every member of a guideline development group is required to complete a disclosure of interest form, which lists any financial or non-financial conflicts of interest. Financial conflicts of interest occur when an individual or organization receives income that could be influenced by the recommendations in the guideline. Examples of this include:

• Personal financial gain such as paid work, consulting income or honoraria and travel stipends;

• Support for research, including direct monetary contributions or donations of equipment, laboratory space, etc.;

• Proprietary interests and patents; grants, fellowships or other financial support to the individual or to their institution; and

• Stock shares or bonds in a commercial entity

For example, a conflict might exist if someone earns a significant portion of their income from a treatment being considered in the guideline or receives research grants from a company producing a drug under evaluation.

Non-financial interests, on the other hand, refer to “roles or positions that might interfere with objective assessment of a body of evidence.” These include:

• Prior publication of a study or systematic review that is part of the evidence base under consideration in the guideline;

• Prior public declaration of a firm opinion or position, as in public testimony during a regulatory or judicial process, or in an editorial in a journal; or

• Professional or personal affiliation with an organization advocating for products or services related to the subject of the guideline

The management of conflicts of interest varies based on the monetary value of the interest, the duration and depth of the competing interest, and the potential for harm arising from the conflict. Some conflicts may be addressed simply by declaring them, while others may necessitate restricted participation or even disqualify a potential member from the group.

Specifically, in the case of a guideline development group, the WHO handbook mandates that chairs, co-chairs, or vice-chairs must not have any financial conflicts. If avoiding intellectual conflicts is impossible, these leaders should represent a diverse range of views. The majority of general members should be free from both financial and non-financial conflicts of interest. Additionally, members should represent “diverse perspectives, training and experiences to keep the recommendations from reflecting a single viewpoint that was conceived before examining and discussing the systematic review of the evidence.”

However, the proposed membership of the current guideline development group blatantly violates these principles. The published biographies of 14 out of 21 members reveal clear and significant financial and non-financial conflicts of interest, and there may be undisclosed conflicts as well.

The group includes three former WPATH presidents: Walter Bockting, Gail Knudson, and Walter Bouman. Knudson and Bockting are co-authors of the 7th edition of the WPATH Standards of Care (SOC7), and both also contributed to the 8th edition (SOC8). All three have published research that will be evaluated during the guideline development process. Additionally, Dr. Bouman’s clinical practice that provides “gender affirming” treatments presents a direct financial conflict.

Several other members also have close ties to WPATH. Chris McLachlan is involved with the Professional Association of Transgender Health, South Africa (PATHSA), and serves on WPATH’s board. Elma de Vries is an executive member of PATHSA and a co-author of South Africa’s gender affirming guidelines. Sanjay Sharma, founding director and CEO of the Association for Transgender Health in India, also serves on the WPATH board.

Another prominent organization in the working group is Global Action for Trans Equality (GATE). Three members of the WHO’s guideline development group—Cianán Russell, Erika Castellanos, and Eszter Kismödi—have disclosed involvement with GATE. Notably, GATE strongly advocates for the availability of gender-affirming treatments for children and adolescents.

In addition to these affiliations, many group members are active in transgender activism within their respective countries. A notable example is Florence Ashley, a “transfeminine jurist” from Canada, whose academic work primarily focuses on the topic of conversion therapy. Ashley contends that conversion therapy encompasses any form of therapy that does not immediately affirm a patient’s self-declared identity.

While the WHO handbook acknowledges that intellectual conflicts are often unavoidable, it also emphasizes the importance of managing them by ensuring representation of diverse perspectives. However, this working group is almost entirely composed of staunch advocates for the medical model of gender care, neglecting representation from the many experienced clinicians and researchers who have raised concerns about this model.

Notably, over half of the committee members identify as transgender. While including members of the impacted community in a guideline development group is appropriate, personal experiences can introduce biases in evaluating evidence. This evaluation should encompass the experiences of the entire affected population. Typically, individuals who join transgender advocacy organizations are satisfied with their decision to transition and the outcome of their medical treatment. Consequently, they may discount or dismiss the experiences of detransitioners and those who experience serious regret.

Normally, guideline development groups are required to include a methodologist with specialized expertise in the evaluation of research studies and guideline development. This working group lacks a member with such qualifications.

Furthermore, the time window for consultation appears strategically designed to limit input from European clinicians critical of the affirming care model. The final group membership was announced on December 18, with a submission deadline of January 9. Considering that the Christmas holidays in Europe usually extend from December 24 to January 6, many European academics will not be turning on their computers during this period.

It might be claimed that the WHO’s guideline development process requires integrating considerations of equity, human rights, gender, and social determinants into its guidelines. The Handbook, however, makes it clear that addressing these issues systematically at each stage of the process is essential. This does not imply that a development group should be stacked with political activists favoring one perspective.

There appears to be a sense of panic in this rushed process. WPATH and the affirming care model are facing increasing scrutiny. Countries like Finland, Sweden, Denmark, and Norway have all abandoned the WPATH Standard of Care. The upcoming Cass Review report, expected in early 2024, is likely to confirm a similar shift in the United Kingdom. Serious questions about the affirming care model are also emerging in France, Germany, the Netherlands, and Australia. New Zealand’s new government is also anticipated to initiate changes. The release of the WPATH files, revealing the internal dynamics behind the creation of SOC8, is set to further damage WPATH’s already fragile reputation.

WPATH once aspired to be a respected scientific and clinical organization. However, the takeover by activists, who marginalized those skeptical of medical transition, led to the endorsement of truly bizarre practices, including the recognition of eunuchs as a gender identity. With WPATH’s credibility rapidly eroding, gender activists scrambled to find another organization to provide a veneer of scientific legitimacy to their ideologically-driven model of care. The WHO appeared to be an easy target. However, they did not account for the fact that WHO, unlike WPATH, is an established organization with clear rules and procedures. By flouting these rules so blatantly, gender activists have made their lack of good faith much harder to ignore.

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Sign the Petition

The first meeting of this panel has already been scheduled for February 19-21, 2024 at the WHO headquarters in Geneva. The meeting’s stated agenda is to “interpret the evidence,” “formulate recommendations,” and “suggest implementation” regarding promotion of gender-affirming treatments, clinician education, health policies, and laws concerning self-ID.

If you share concerns that include (1) a biased panel composition; (2) failure of panel members to disclose conflicts of interest so they can be properly managed; (3) a brief and perfunctory public consultation period (too short and over Christmas); and (4) the breathtakingly rapid speed of the entire guideline development process, consider reading and signing the petition below.

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