The World Health Organization is promoting controversial ‘gender-affirming’ approach on a global scale

An open letter to the Department of Health and Social Care (DHSC) in the UK and the World Health Organisation (WHO)

When teenagers tell their parents they are trans and must urgently undergo medical transition, most parents do not know what to do. Whilst parents are prepared to stick with their children through thick and thin, and many would not bat an eyelid at gender non-conforming clothes or similar ways of self-expression, it is the medical aspect of gender reconstruction that often does not sit right with the parental instincts to keep their loved ones safe. Side effects of cross-sex hormones and surgeries offered to transgender patients are significant: they include permanent changes to fertility and sexual function, increased risk of cardiovascular disease and increased risk of suicide. No wonder parents are researching the risks and alleged benefits of these medical interventions. They are looking for healthcare guidelines that are evidence-based and have a solid scientific basis. Unfortunately, at this time, such guidelines simply do not exist. From basic definitions of what constitutes being trans, to diagnostic criteria and treatment options, healthcare for gender questioning youth is a matter of an international debate. Medical interventions that some activist groups claim to be life-saving, other professionals describe as causing irreversible damage^[1] and contributing to the biggest medical scandal of this generation^[2][3].

Despite the lack of consensus about the nature of gender dysphoria, let alone the appropriate clinical response, the World Health Organization is pressing ahead with developing global guidelines on the health of gender-diverse people^[4]. It appears that the key areas of focus of the guidelines have already been decided upon, although it is not clear how this was agreed, when and by whom. Two of the proposed areas of focus – “provision of gender-affirming care” and “legal recognition of self-determined gender identity” – are of particular concern.

“Provision of gender-affirming care” implies that diagnostic criteria for gender dysphoria and gender incongruence are well defined and universally accepted across the world. It also implies that gender-affirming care is evidence-based, safe and recognised as the preferred approach. The most recent findings in the UK do not support this. NHS child gender identity service has been rated as inadequate by The Care Quality Commission in 2021, calling for more holistic care, introduction of psychotherapy as the first line of treatment and the call for better quality of data. Benefits of puberty blockers and cross-sex hormones for patients under 18 years old have been shown to be of very low certainty by the UK National Institute for Health and Care Excellence (NICE). Hilary Cass’s review of gender service highlighted that social transitioning is not a neutral act^[5], and Department of Education advises schools in England to take a very cautious approach if pupils want to use a new name, pronouns or wear gender non-conforming uniform^[6]. Mermaids, a British charity advocating for gender affirmation, is currently under investigation by The Charity Commission over safeguarding concerns, and Department for Education has removed it from its mental health and wellbeing resources for schools^[7].

Similar concerns about gender-affirmative approach have been raised in other European countries. In Ireland, leading doctors Prof O’Shea and Dr Moran made a formal complaint to the Health Information and Quality Authority (HIQA) about the gender-affirming model and the harm it causes to children^[8]. In Finland, Dr. Riittakerttu Kaltiala, who helped to pioneer gender-affirming care since 2011, warns that gender reassignment of minors is an experimental practice. National Board of Health in Sweden and The Academie Nationale de Medecine in France recently came to a similar conclusion. Medical gender reassignment procedures for minors are illegal entirely in Poland and in Hungary.

None of these concerns are well represented by the people selected for the WHO Guideline Development Group. In fact, the group consists of trans activists, past and present members of controversial WPATH association^[9], and experts in HIV/AIDS^[10]. Most of the members have serious, undeclared conflicts of interest due to their work in the gender-affirming industry, which could prevent them from making decisions in the best interests of the global community. There is no representation in the panel at all from Sweden, France, Ireland, Finland and Eastern Europe. Representation from the UK is limited to Prof Walter Bouman, past WPATH president and strong advocate for gender-affirming care, who is currently recruiting patients for a research study on genital gender surgery^[11].

“Legal recognition of self-determined gender identity” is another area that WHO is proposing to issue guidelines on, despite the vast majority of WHO member states, including the UK, not supporting this idea due to the negative impact of self-ID on women’s sport, women’s prisons and single-sex spaces. Interests of women, children and vulnerable people are not represented in the WHO Guideline Development Group (GDG).

Finally, it is alarming that there is no mention and no representation of interests of the growing number of de-transitioners and desisters – people who have been harmed by gender-affirming care. Experiences of Keira Bell, Ritchie Herron and Sinead Watson, amongst others, can teach us a lot about the fleeting nature of transgender ideation and the intersection of gender identity with co-occurring conditions such as autism, ADHD, trauma, poor mental health and internalised homophobia. Excluding de-transitioners from this debate means turning a blind eye on what we know to be important ethical issues in gender identity care.

Our Duty parents’ group will be providing feedback to WHO at the designated (and somewhat odd for this purpose) email hiv-aids@who.int, advising the following:

1. Blatant bias and undisclosed conflicts of interest
Multiple members of the Guideline Development Group (GDG) are working in organisations that directly benefit from the promotion of gender-affirming care. All conflicts of interest must be identified, disclosed and addressed. Undisclosed conflict of interest is unacceptable because it could lead to poor decisions and does not serve the interests of the global community. The group must represent the diversity of opinion on gender related healthcare and not be limited to promoting gender affirming approach. Geographical coverage must be improved to include better representation from European Region. Expertise in the group must correspond with the issues discussed: currently HIV/AIDS and gender-affirmative expertise is overrepresented, but expertise in transition regret, co-morbidities such as neurodiversity and trauma, women’s rights, safeguarding, vulnerable patients, fertility, ethical challenges of informed consent, aetiology of gender dysphoria, impact of the gender transition on families, and legal matters are not represented well enough.
The group should also include an expert on guideline development skilled in the processes and methods for developing evidence-based, rather than ideology driven, guidelines.

2. Short timeline
WHO Guideline Development Group (GDG) was announced on the 18 December 2023, and plans to meet at WHO’s headquarters in Geneva on 19-21 February 2024. Opportunity for comments from the general public is open until 8 January 2024, leaving alarmingly little time for providing feedback on the composition of the panel, content of the discussion and due process. Not providing sufficient time reduces the quality of responses. It is recommended that the consultation period is extended to a minimum of 6 weeks, and the meeting in Geneva is postponed until all feedback is collated, responded to, and acted upon.

3. Key areas of focus
Key areas of focus for the guidelines are outlined using language that is not neutral and implies international consensus that does not exist. It is essential that key areas of focus are agreed in a transparent way. Some of the important questions that were not included are: establishing clear definition of terms, diagnostic criteria, lack of data and loss to follow up, ethical aspects of informed consent, neurodiversity, safeguarding, vulnerable patients, social contagion amongst children and young people, fertility issues, risks associated with black market cross-sex hormones and unregulated private providers.

The UK government is one of the biggest WHO donors in the world, with USA, Bill & Melinda Gates Foundation and Germany being the other main contributors^[12]. It is crucial that the Department of Health and Social Care in the UK government responds to WHO proposed development of new guidelines on gender care with a request to review the process in its entirety, including the proposed agenda, the composition of the working group and timescales. Agenda must align with the needs of the UK citizens, take into account recent findings of the Hilary Cass review, guidance on social transitioning published by the Department of Education, and de-transitioners perspective. We ask the UK’s representative on the Executive Board of the World Health Organisation, Chief Medical Officer Professor Chris Whitty, to formally respond to this letter.

Gender questioning patients in the UK and their families deserve access to all possible treatment options, not just invasive medical interventions that benefit interests of certain activist groups and pharmaceutical companies. We need guidelines that are evidence-based, developed responsibly, and not rooted in ideologically driven language. By falling short of these basic standards, we may be failing the whole generation of young people.