Leading medical expert says Govt must remove WPATH trans guidelines

A leading Irish medical expert on gender dysphoria has said that WPATH guidelines around transgender care must be removed from the Programme for Government after a landmark review into services for children found a lack of evidence for the guidelines. 

He also warned that the HSE continued to give Irish children “unsafe treatment” for gender dysphoria, despite the “unfit” Tavistock being closed down – and that this must “be stopped immediately”.

WPATH – the World Professional Association of Transgender Healthcare – was “highly influential in directing international practice, although its guidelines were found by the University of York appraisal process to lack developmental rigour” the review by paediatrician Hillary Cass found.

The WPATH guidelines moved from an earlier more cautious approach to advocating social transition for children – facilitating the pathway to changing sex – and to supporting what has been described as “gender affirming care”, which led to an unquestioning acceptance that children could be set on a pathway to transition, which could eventually include hormonal interventions and surgery, without sufficiently addressing underlying mental health problems.

Dr Paul Moran, who developed the National Gender Service (NGS) Model of Care with the HSE, and is a member of the Cass Review Clinical Expert Group, said that the NGS had advised the government as early as 2018 that the WPATH guidelines were “unsafe and unsuitable”.

“Despite this, WPATH SOC8 have been included in the Programme for Government,” he wrote in TheJournal.ie. “The Programme for Government does not contain clinical guidelines for other areas of medicine.”

“The Cass Review could only recommend two guidelines for practice – the Finnish guideline published in 2020 and the Swedish guideline published in 2022. Clearly, the Irish government needs to remove the WPATH guidelines from the programme for government and instead adopt the Cass Report as the key policy document.”

The Cass Report observed that WPATH moved from a ‘watchful waiting’ approach for children to a position of advocating for social transition.

It also found that WPATH’s claims that its guidelines was based on evidence on improved mental health outcomes with social transition – and that not allowing a child to socially transition may be harmful – were not supported by the findings of the University of York’s systematic review carried out for the Cass report.

The Cass review warned that healthcare professionals are afraid to discuss views on transgender services for children, and found there was no evidence puberty blockers or hormone drugs ‘buy time to think’ or ‘reduce suicide risk’ in that cohort.

Dr Cass made 32 recommendations, including an end to the prescribing of powerful hormone drugs to children and adolescents (under-18s), while also insisting that children who referred for gender services be screened for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.

Outlining the research she had undertaken and the stakeholders she had spoken to, Dr Cass said that “despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional”.

“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop,” she wrote.

“The Cass report is the most comprehensive review of available evidence, experience and expertise ever conducted”, Dr Moran said.

There was extensive inclusion of the lived experience of patients and families and inclusion of gender advocates and support groups. A wide range of professional expertise was involved including both gender specialists and other clinicians.

Most important was the analysis of all available published and unpublished research and audit evidence.

He said that “perhaps the most important issue identified at the outset is the lack of high-quality evidence in this area. This echoes the findings of other recent international reviews including the systematic review published by the Swedish government last year and that published by the German government earlier this year.”

“The quality of research that has been published in peer reviewed journals in this area is truly appalling and would never be accepted in other areas of medicine,” he added.

Dr Moran pointed out that there was “no evidence that puberty blockers bought time to think” and that “there were risks of harm to psychosocial wellbeing and cognitive development, and bone density was compromised.”

“Many of these children went on to have cross sex hormone treatment and some are now infertile,” he said, warning that the HSE continued to give Irish children “unsafe treatment”  despite the “unfit” Tavistock being closed down – and that this must “be stopped immediately”.

Despite this evidence, as well as the warnings from the clinicians at the National Gender Service and the UK government and independent investigations, the HSE continued to give Irish children this unsafe treatment and when the UK government shut down the unfit Tavistock, the HSE set up a new arrangement with a private clinic in Belgium to do the same thing, which is still going on. This must be stopped immediately.

He said that the Cass report “also highlights the dangers of private gender healthcare which is also rampant in Ireland. The four main issues around private gender healthcare are the potential for conflict of interest, more limited assessment, a lack of regulation and a narrow focus on gender-only issues without the broader MDTs to address the other problems these children have.”

There is an inherent conflict of interest involved in providing gender healthcare privately. Where time is money, the extended assessments many children need are not possible, and online, remote assessments are more prevalent in private gender services which in my view, gives a lower quality of clinical assessment in these cases.

HIQA regulates public health services, but there is no equivalent statutory body to regulate private healthcare. The Cass Report has called on the UK government to examine the implications of private healthcare, and I believe the Irish government should also take measures to protect Irish children from any potential issues.

A look at the key findings of the Cass report can be found here and here.