An Open Letter to the World Health Organization

Re: WHO Guidelines on the Health of Trans and Gender Diverse People

Therapy First has sent the following letter to the World Health Organization in response to their formation of a biased Guideline Development Group (GDG) tasked with creating a guideline on the health of trans and gender diverse people. 

Meg Doherty, MD, PhD
World Health Organization
Avenue Appia 20
1211 Geneva
Switzerland

Re: WHO Guidelines on the Health of Trans and Gender Diverse People

Dear Dr. Doherty,

I am writing on behalf of Therapy First, an international community of hundreds of mental health clinicians who work with gender questioning young people. We are a US-based non-profit organization dedicated to making high quality mental healthcare accessible to gender dysphoric children, adolescents, and young adults. Acknowledging the poor quality of evidence in support of medical interventions for gender dysphoria, we advocate for psychosocial support as a first-line intervention for young people struggling with gender issues and urge caution in recommending irreversible interventions for this population.

In response to WHO’s formation of a Guideline Development Group (GDG) for trans and gender diverse people, we recommend the WHO to pause the process and restructure the group to represent the diversity of professional views on this complex matter. The science is far from settled. There are risks, both known and unknown, involved in the medical interventions offered to treat gender distress, and the benefits have not been clearly proven to outweigh the potential harms. Especially considering the burgeoning numbers of adolescents and young adults identifying as transgender and seeking medical interventions in recent years, the GDG needs to be able to review the existing evidence critically, without being unduly influenced by conflicts of interest or ideological commitments.

Pausing and restructuring the GDG will allow for the WHO’s guidelines to better reflect the multifaceted nature of gender incongruence and the rapidly developing body of evidence on its treatment. As it stands, however, the proposed members of the GDG have a strong bias towards medical interventions as a first-line treatment for gender incongruence. Although this is a highly contentious area of healthcare, there is no diversity of opinion represented by the current proposed structure of the GDG. Some members of the panel have even gone as far as to dismiss psychotherapy as a treatment for gender dysphoria, referring to it as “conversion therapy.”

Contrary to this inaccurate and biased characterization, psychotherapy provides individuals with the opportunity to carefully reflect on identity, deepen an understanding of their relationship to gender, and bolster insight in ways that support their capacity to make informed decisions that are right for them. In this way, autonomy and self-determination are encouraged through providing each patient the space to have a personalized process. Therapy First recognizes a tension between psychotherapy’s traditionally open principles of curiosity and exploration and the now popular gender affirming approach which is restrictive, rather than expansive, in its one-size-fits all treatment pathway. When properly practiced, psychotherapy addresses gender distress in a comprehensive and individualized manner, considering developmental stages, social and cultural factors, comorbid psychiatric conditions, as well as the interplay of sexual orientation and identity formation. 

Additionally, the GDG does not include anyone who has detransitioned or any clinicians who are familiar with this growing population. Having representation for those who have undergone hormonal and/or surgical treatments and subsequently experienced harm and have chosen to reverse treatments is vital. This will not only contribute to a more nuanced and balanced guideline development process, shedding light on diverse outcomes and ways of mitigating risk factors associated with gender-affirming interventions, but will also align with the WHO's commitment to incorporate varied perspectives and experiences to enhance the quality, safety, and relevance of its guidelines.

I’m attaching here Therapy First’s Clinical Guide for Therapists Working with Gender Questioning Youth and request that you consider including a member from Therapy First’s professional association in a newly constituted GDG.

Sincerely,
Paul Garcia-Ryan, LCSW
President
Therapy First
New York, New York