Hysterectomies for 17-year-olds? WPATH tries to scrub the record
I’m guessing this interesting set of ‘corrections’ is the reason for WPATH’s strange, last-minute delay releasing releasing the eighth standards of care. Just as I predicted last week, when I mentioned that it’s a terribly inconvenient time for WPATH to recommend lowering the age limit for “gender-affirming” surgeries.
Here’s what the authors removed from the standards of care:
Some sections of text have been removed or added. Please see below.
On page S45, at the end of the sentence finishing “are critic.” The following was added: “However, these findings have not been replicated.”
On page S48: the following text was removed:
“With the aforementioned criteria fulfilled (6.12.a–6.12.g), the following are suggested minimal ages for gender-affirming medical and surgical treatment for adolescents:
14 years and above for hormone treatment (estrogens or androgens) unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
15 years and above for chest masculinization unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
16 years and above for breast augmentation, facial surgery (including rhinoplasty, tracheal shave, and genioplasty) as part of gender-affirming treatment unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
17 and above for metoidioplasty, orchidectomy, vaginoplasty, hysterectomy, and fronto-orbital remodeling as part of gender-affirming treatment unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
18 years or above for phalloplasty unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.”
On page S54, the following text was removed:
“Many youth who bind may require chest masculinization surgery in the future (Olson-Kennedy, Warus et al., 2018).
On page S65, the following text was removed:
“With the aforementioned criteria fulfilled (6.12.a–6.12.g), the following are suggested minimal"
And the subtitle in bold was changed to read as follows:
"Consideration of ages for gender-affirming medical and surgical treatment for adolescents"
On page S65, the following text was removed:
“14 years and above for hormone treatment (estrogens or androgens) unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
15 years and above for chest masculinization unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
16 years and above for breast augmentation, facial surgery (including rhinoplasty, tracheal shave, and genioplasty) as part of gender-affirming treatment unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
17 and above for metoidioplasty, orchidectomy, vaginoplasty, hysterectomy, and fronto-orbital remodeling as part of gender-affirming treatment unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
18 years or above for phalloplasty unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.
The ages outlined above provide general guidance for determining the age at which gender-affirming interventions may be considered. Age criteria should be considered in addition to other criteria presented for gender-affirming interventions in youth as outlined in Statements 6.12a-f. Individual needs, decision-making capacity for the specific treatment being considered, and developmental stage (rather than age) are most relevant when determining the timing of treatment decisions for individuals.
On page S65, the phrase:
Higher (i.e.., more advanced) ages are provided for treatment with greater irreversibility, complexity, or both.
Was changed to read:
Higher (i.e.., more advanced) ages may be required for treatment with greater irreversibility, complexity, or both.
On pages S65-S66, the following text was removed:
“The recommendations above are based on available evidence, expert consensus, and ethical considerations, including respect for the emerging autonomy of adolescents and the minimization of harm within the context of a limited evidence base. Historically, there has been hesitancy in the transgender health care setting to offer gender-affirming treatments with potential irreversible effects to minors. The age criteria set forth in these guidelines are younger than ages stipulated in previous guidelines and are intended to facilitate youth’s access to gender-affirming treatments (Coleman et al., 2012; Hembree et al., 2017). Importantly, for each gender-affirming intervention being considered, youth must communicate consent/assent and be able to demonstrate an understanding and appreciation of potential benefits and risks specific to the intervention (see Statement 6.12c).”
On page S66, the following text was removed:
“It should also be noted the ages for initiation of GAHT recommended above are delayed when compared with the ages at which cisgender peers initiate puberty with endogenous hormones in most regions (Palmert & Dunkel, 2012).”
On page S66, the following text was removed:
“Age recommendations for irreversible surgical procedures were determined by a review of existing literature and the expert consensus of mental health providers, medical providers, and surgeons highly experienced in providing care to TGD adolescents.”
On page S258, the following text was removed:
“The following are suggested minimal ages when considering the factors unique to the adolescent treatment time frame for gender-affirming medical and surgical treatment for adolescents, who fulfil all of the other criteria listed above.
Hormonal treatment: 14 years
Chest masculinization: 15 years
Breast augmentation, Facial Surgery: 16 years
Metoidioplasty, Orchiectomy, Vaginoplasty,
Hysterectomy, Fronto-orbital remodeling: 17 years
Phalloplasty: 18 years”
The authors had to list the ‘corrections’ they made after the final publication was approved. The corrections are all age-related. WPATH prefers specifying no age limits whatsoever to going on the record by endorsing cross-sex hormones at 14; double mastectomies at 15; breast augmentation and facial surgery at 16; metoidioplasty, orchiectomy, and vaginoplasty, hysterectomy at 17; and phalloplasty at 18.
And these weren’t even minimums. In every case, as you can see in the text removed from page S48, every single ‘minimum’ included the addendum “unless there are significant, compelling reasons to take an individualized approach when considering the factors unique to the adolescent treatment time frame.” ‘Individualized’ means younger. Younger than 15 for double mastectomies. Younger than 17 for hysterectomies.
Apparently (and rather belatedly!), WPATH decided that “hysterectomies at 17!” is a bad look for an organization whose members are committed to pretending nobody’s performing such surgeries on underage patients. But the surgeries are already happening and WPATH intended to explicitly lower age recommendations to “facilitate youth’s access to gender-affirming treatments”—in other words, to ensure that even more children go under the knife. WPATH can’t change course—the standards of care were all ready to go and their surgery-happy membership would balk—so the best they’ve got is plausible deniability.
So the question is, did they do this to appease angry non-WPATH MDs who needed cover for the surgeries they had done/were doing on younger children? Or was this the plan all along, pandering to members who wanted at least some (way too low) age limits and then pulling a fast one at the last minute? In either case, how does this not result in internal strife and bad PR? How would we not see a storm of angry WPATH members complaining to the press? (Ah, the press… never mind on that one.) Or does any of that matter when the gender clinicians are just using the vagaries of the SoC as coverage for whatever they do? It's not like they were of any value before this version.
I keep thinking too rationally about this, expecting that a move like this — a quick "presto change-o" — would somehow draw negative attention and tarnish the entire effort. I forget the world we now inhabit.
I totally cosign your interpretation, Eliza. The publicity in the wake of the LibsOfTikTok publicizing underage surgeries just got too hot. But expunging the minimum age recommendations, spongy though they were, has opened the floodgates wide to the least-scrupulous health care providers. What lurks behind the gates is shocking even to me, and I'm hardly naive.
I read the short - rather dismissive and distorted - section on detransitioners, and the first part of the adolescence chapter. Then I decided to skip ahead and read the eunuch and nonbinary chapters because they're relatively short. Subsequently I tried to resume the SOC chapter on adolescents but had to stop because I'm still too queasy from the eunuch material.
I couldn't believe that the online eunuch archive they cited in the text (not merely a footnote!!!!) of the SOC was the same one Genevieve Gluck has reported on, so I went to check. Yup. Same archive. The stories are still up, too, though to get more than a sampler you have to register as a member. For anyone who'd prefer to protect their sanity, don't go there. The eunuch stories are brimming with sexual sadism. Truly horrific.
But precisely this site is touted as the font of eunuch knowledge: "While there is a 4000-year history of eunuchs in society, the greatest wealth of information about contemporary eunuch-identified people is found within the large online peer-support community that congregates on sites such as the Eunuch Archive (www.eunuch.org), which was established in 1998." (p. 88) WPATH suggests eunuch-identified people "may also benefit from a eunuch community" (ibid.). No other community is mentioned apart from this archive of extreme sexual sadism and masochism that eroticizes genital mutilation, including of underage boys, and delights in rape of boys and men.
The stories are presented as fiction. But the stories run parallel to discussion forums, blogs, and other resources that aren't accessible at all to non-members. The stories are the only public-facing element of the site. They're the teaser, drawing potential new members into this "community."
The nonbinary chapter is laundering this straight-up chamber of horrors. Please stop reading now if you're squeamish, as the following quotation is graphic. The recommendations for male (AMAB) people advise:
"In the case of vaginoplasty, individuals should be advised lack of testosterone-blocking therapy may cause postopera- tive hair growth in the vagina when hair-bearing skin graft and flaps have been used (Giltay & Gooren, 2000).
"Additional surgical requests for nonbinary people AMAB include penile-preserving vaginoplasty, vaginoplasty with preservation of the testicle(s), and procedures resulting in an absence of external primary sexual characteristics (i.e., penectomy, scrotectomy, orchiectomy, etc.). The surgeon and individual seeking treatment are advised to engage in discussions so as to understand the individual’s goals and expectations as well as the benefits and limitations of the intended (or requested) procedure, to make decisions on an individualized basis and collaborate with other health care providers who are involved (if any)." (p. 87)
This is what lies beneath the glittery promises of gender euphoria, trans joy, authenticity, and "living your best life" sold to our young people. I do know adult trans people who are quite satisfied with changes they've made to their bodies (though I dearly wish they'd never felt the need). But we're now so far beyond alleviating severe dysphoria and deep into mass sociogenic self-harm that it's hard to imagine many of my fellow liberals would support this approach to "medical care" if they knew the truth.
"Protect trans kids," indeed.