As a psychiatrist, I have seen an explosion of gender-dysphoric youth and young adults in recent years. These vulnerable groups deserve compassionate, evidence-based care. I am concerned that the recent BCMJ content on gender dysphoria presents gender-affirming care as evidence-based and as the only appropriate model of care. This premise forms the basis for the three articles that follow on the medicalized treatment of gender dysphoria.
The World Professional Association for Transgender Health (WPATH) Standards of Care Version 7 (SOC7) are not evidence-based. The WPATH website clearly states that SOC8 is the first version being developed using an evidence-based approach. In addition, a systematic review of its clinical practice guidelines states that SOC7 “contains no list of key recommendations or auditable quality standards.” Furthermore, “many recommendations are flexible, disconnected from evidence and could not be used by individuals or services to benchmark practice.”
Finland, Sweden, Norway, and the UK are re-evaluating care of gender-dysphoric youth due to concerns about medical harm and the uncertainty of benefit.
I find it disconcerting that the validity of SOC7 and the gender-affirming model are wholeheartedly accepted and promoted by these articles. There is no balanced discourse of reported negative outcomes or alternative approaches.
Further, some high-profile members of WPATH have gone on record stating their concerns. Dr Marci Bowers, a trans woman surgeon, publicly disclosed her concerns about puberty blockers, particularly the age at which they are started. Psychologists Drs Laura Edwards-Leeper and Erica Anderson (a trans woman), have raised questions about the significant rise of gender-dysphoric youth, particularly adolescent girls. They have advocated for thorough psychological assessment and questioned the potential harm of not providing exploratory therapy.
While WPATH SOC8 may provide an opportunity for evidence-based guidelines, a review of the draft raises concerns. For example, the section on “eunuchs,” presented as a unique gender identity, was bewildering. I question the evidence for this category, and particularly the recommendation to “affirm” and refer for surgical castration lest they attempt self-castration.
For those hesitant to agree, I urge you to watch the Swedish Trans Train documentaries (part 1: https://youtu.be/sJGAoNbHYzk). Canadian physicians should not ignore the potential risks of the affirmation model when there is international evidence of harm to vulnerable youth. Distressed youth deserve diligent, nuanced care favoring psychological assessment and care over medical harm. Concerningly, Bill C-4 (banning conversion therapy) was recently passed by the Senate. Without a clear definition of what constitutes exploratory therapy versus conversion therapy, therapists risk being charged under this bill and may be dissuaded from treating people with gender dysphoria at all.
We are in a unique position to rethink the treatment model for gender dysphoria. I hope we can begin a dialogue, so that our youth can get the treatment they need and deserve. Gender affirmation is not a one-size-fits-all model. To allow ideology to prevail over sound medicine is negligent at best.
—Joanne Sinai, MD, MEd, FRCPC
This letter was submitted in response to “Guest editorial: Gender-affirming care in British Columbia, Part 1,” “Gender-affirming primary care,” “Endocrine treatment of transgender and gender-diverse people,” and “Gender-affirming surgical care in British Columbia.”
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3. Society for Evidence-Based Gender Medicine. The signal—and the noise—in the field of gender medicine. 31 January 2022. Accessed 17 February 2022. https://segm.org/flawed_systematic_review_puberty_blockers.
4. Shrier A. Top trans doctors blow the whistle on “sloppy” care. Common Sense. 4 October 2021. Accessed 17 February 2022. https://bariweiss.substack.com/p/top-trans-doctors-blow-the-whistle.
5. Edwards-Leeper L, Anderson E. The mental health establishment is failing trans kids: Gender-exploratory therapy is a key step. Why aren’t therapists providing it? Washington Post. 24 November 2021. Accessed 17 February 2022. www.washingtonpost.com/outlook/2021/11/24/trans-kids-therapy-psychologist.
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