December 28, 2023 - 4:45pm

A few days before Christmas, the World Health Organization (WHO) announced that it would be developing guidelines on “the health of trans and gender diverse people”, with a focus on access to hormones and surgeries (what it calls “gender-inclusive care”) and legal recognition of gender self-identification. 

The WHO also announced the formation of a guideline development group. This panel of experts is heavily stocked with apparatchiks from the World Professional Association of Transgender Health (WPATH), including two former presidents; trans activists employed by the Global Action for Trans Equality network, or GATE; the parent of a trans-identifying child; and at least one member with strong ties to the pharmaceutical industry. 

A few of the panellists have especially colourful public profiles, none more so than Florence Ashley, a “transfeminine jurist and bioethicist” whose preferred pronouns are “They/Them/That Bitch”. Ashley believes that “puberty blockers ought to be treated as the default option” for all youth, as opposed to “letting puberty runs its course”. The activist argues that letting this stage of human development progress uninterrupted “strongly favours cis embodiment by raising the psychological and medical toll of transitioning”. Thus: 

… Puberty blockers structurally place transgender and cisgender hormonal futures in approximate symmetry. Youth who take puberty blockers have their options wide open, their bodies unaltered by either testosterone or oestrogen. Although much remains unknown about the long-term effects of puberty blockers, limited empirical evidence and clinical experience make us more than justified in assuming that whatever risks puberty blockers have do not foreclose future life paths as much as undergoing puberty does.
- Florence Ashley

Besides being absurd, this proposal discounts the possible effects of puberty blockers on adolescent brain development. We don’t yet know how suppressing the sex hormones that spur cognitive development during puberty affects factors like impulse control, emotional regulation, critical thinking, and decision-making. What’s more, evidence suggests that blocking puberty may “lock” children into a trans identity, rather than buying time and space to think. 

Ashley has argued elsewhere that clinical assessment does not predict or prevent regret (so why bother?) and dismissed concerns about the rapid increase in adolescent and young adult females seeking transition. Ashley concludes on an odd note, first denying, then embracing the possible role of social influence: “If the rise in transgender identities evidences social contagion — a claim I have shown to be unsubstantiated — it may yet be a healthy contagion.” This comes from the philosopher who once mused: “What is your main motivation in life, and why is it getting railed in a sundress by a hot dyke?”

Another panellist, Teddy Cook, described the “actual side effects of gender-affirming medical care” as “a significantly improved quality of life, significantly better health and wellbeing outcomes, a dramatic decrease in distress, depression and anxiety and a substantial increase of gender euphoria and trans joy”, concluding that “we are not at risk of harm by affirming our gender.” 

Panellists with WPATH-heavy résumés oversaw the controversial inclusion of eunuchs, as well as the exclusion of a draft chapter on medical ethics, from that organisation’s most recent standards of care. In short, many of them have significant personal, intellectual, and professional conflicts of interest that may interfere with their ability to evaluate and follow the evidence when that evidence leads to uncomfortable places. 

Conflicts of interest are unavoidable, but balance matters. One won’t find any critics, concerned clinicians, experts in child and adolescent development, specialists in neurodevelopment, or desisters and detransitioners in the WHO’s guideline development group. 

The organisation also opened a brief window for public comment over the Christmas holidays — a window that closes just two days after Epiphany. If Friday afternoons are the best time of the week to dump bad news, the quiet stretch around Christmas and New Year is the ideal time to solicit public comment — if one wants as few people as possible to weigh in, that is. 

The World Health Organization has a responsibility to facilitate — not preempt — an open, transparent, and scientific dialogue about the risks, benefits, and unknowns surrounding the most effective and ethical treatments for gender-dysphoric patients. At this point, such a process would require starting from scratch.


Eliza Mondegreen is a graduate student in psychiatry and the author of Writing Behavior on Substack.

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