In recent weeks, the support beams propping up the field of pediatric gender medicine have begun to show signs of critical failure. In early February, journalist Ben Ryan broke the news about the first-of-its-kind payout to a detransitioner, Fox Varian, who was awarded $2 million in damages by a New York jury after undergoing a double mastectomy as a 16-year-old—despite a complex psychiatric profile, troubling family history, and indicators of broader identity instability. This was soon followed by a groundbreaking position statement by the American Society of Plastic Surgeons, which formally came out against surgical interventions for patients under 19, citing the findings of evidence reviews and medical practice reversals in European countries.
During Varian’s case, the World Professional Association for Transgender Health’s Standards of Care were referenced by expert witnesses to contextualize the professional standards governing treatment of adolescents with gender dysphoria at the time of her 2019 surgery. Such guidelines can assist jurors in evaluating whether the providers’ assessment practices aligned with accepted professional safeguards.
“This case was a medical malpractice case, not a referendum on gender-affirming care,” WPATH told the New York Times after the Varian verdict. “When care is delivered ethically and responsibly within these guidelines, the integrity of the field is strengthened,” it went on to add.
Despite the unfavorable risk-benefit ratio of treatment and ethical concerns about a minor’s capacity to consent, WPATH is implicitly maintaining that following its guidelines provides a safe and ethically consistent way to render these treatments. A closer look at the last two iterations of WPATH’s guidelines—Standards of Care 7 and 8, the latter of which has been in effect since 2022—however, reveals that they are shot through with contested, and at times, irreconcilable assumptions about the immutability of trans identities, and the relationship between these identities and mental health issues. Moreover, WPATH’s fundamental emphasis on honoring patient identities and “goals” essentially ensures that in practice the clinical decision-making tree always ends in affirmation.
In malpractice litigation, the “standard of care” is a legal term that reflects what a “reasonably competent or prudent physician would do under similar circumstances.” Because judges and juries are not medical experts, however, they need tangible benchmarks for physician conduct. In practice, medical society statements and clinical practice guidelines are often used as proxies for the “standard of care.” Because WPATH is an international organization with arguably the most influential and widely cited clinical practice guidelines, those guidelines are often used as a benchmark.
WPATH’s guidelines and even their name—the Standards of Care—was developed with litigation in mind. In Boe v. Marshall—a suit challenging Alabama’s law prohibiting minors from accessing medical transition procedures—it was revealed that WPATH was advised by “social justice lawyers” not to include evidence reviews in its SOC-8 because they would put the organization in an “untenable position in terms of affecting policy or winning lawsuits.” Moreover, WPATH’s guidelines, particularly the SOC-8, often emphasize a highly individualized approach to patient care that foregrounds patient “goals” and “wishes,” without defining explicit parameters for when certain treatments are appropriate. Compare these with, say, the clear criteria for managing and treating hypertension in guidelines endorsed by multiple medical associations. Of course, treating hypertension is more straightforward; the condition is unburdened by gender medicine’s diagnostic and philosophical morass. But the treatment of gender issues differs even from more nebulous disorders; almost no mental disorder, for instance, carries with it the possibility of irreversible physical treatments—on otherwise healthy bodies—that gender medicine does.
Moreover, a recent peer-reviewed quality assessment of the SOC-8 determined that the guidelines have key limitations in developmental rigor, editorial independence, and clinical applicability. Three of the eight assessors of the guidelines, furthermore, “recommended not to use the reviewed guideline chapters due to methodological concerns.”
As I’ve written about before, while less attuned observers tend to assume that ostensible safety guardrails and nods to psychological assessment in WPATH’s guidelines make patient regret and harm unlikely, the guidelines’ emphasis on affirmation is at odds with the clinical concept of “differential diagnosis.” WPATH’s guidelines implicitly deprioritize differential diagnosis—drawing clinically meaningful distinctions between disorders that have overlapping symptoms or expressions—by maintaining that other complex mental health challenges are really just secondary to the experience of dysphoria, and not possible drivers of distress.
Similarly, despite often deploying the language of “medical necessity,” WPATH’s SOC-8 pulls a bait and switch by embracing the “gender incongruence” classification—as opposed to “gender dysphoria”—which removes distress as key diagnostic feature and conceptualizes “gender diversity” as a normal, entirely non-pathological way of being in the world. It’s unclear, however, how this understanding of “gender incongruence” necessitates the need for invasive medical interventions. Indeed, one of the biggest differences between the SOC-7 and 8 is that the SOC-7 still made treatment contingent on a gender dysphoria diagnosis, whereas the SOC-8 argues that treatment should be accessible solely based on an identity claim.
The affirmative model’s commitment to uncritically affirming all identity claims, though, helps explain how you end up with high-profile detransitioner malpractice suits—Fox Varian, Soren Aldaco, Chloe Cole, Prisha Mosley, Luka Hein and Isabelle Ayala, among others. Many of these complaints fit a common pattern, often involving highly complex clinical cases that feature multiple psychiatric and developmental issues taking place within challenging family contexts—exactly the kind of cases which would signal to any experienced clinician the need for caution and delayed decision making. Indeed, this is why both WPATH’s SOC-7 and 8 recommend conducting biopsychosocial assessments, taking proper case and family histories, and engaging in “differential diagnosis” to assess the relationship between a child’s identity claim and any preexisting mental health issues.
Indeed, in Varian’s case, trans-identified psychologist Erica Anderson testified that the “standard of care” was not followed when assessing her. Anderson named several deviations from the standard, including failing to acquire informed consent, failing to properly manage comorbidities, and rendering a surgical intervention that was contraindicated for this particular patient (because the formal diagnosis on the record was body dysmorphia, not gender dysphoria).
And yet, WPATH’s current and former guidelines undermine proper assessment and screening by subscribing to the belief that trans identities are largely immutable, and that any comorbid mental health issue must stem from “minority stress,” a theory that presupposes that comorbidities among the trans-identified must be the product of “family/caregiver rejection, and non-affirming community environments.” Meanwhile, critics contend that the “minority stress” literature is based on self-report surveys which overlook the possibility of reverse causality: Preexisting mental health issues that often predate a transgender identity lead to more negative appraisals of ambiguous events, culminating in subjective reports of stigma and rejection. Similarly, the SOC-8 argues that mental health comorbidities that interfere with “diagnostic clarity” or “decision making” should be “prioritized and addressed,” but it simultaneously asserts that this “does not mean all mental health challenges can or should be resolved completely” prior to interventions like hormone therapy and surgery.
Fox Varian’s case lays bare the clinical realities of the affirmative model. Notably, Varian’s treating psychologist was initially working with her on emotion regulation strategies for preexisting depression and anxiety, as well as how to handle peer challenges and issues with her parents. Varian was also diagnosed with autism at 14. Varian’s parents also reportedly had histories of abusing drugs and alcohol.
What’s more, within three months of discussing the possibility of being trans-identified with her psychologist, Varian was bringing up “top surgery” despite never undergoing any endocrinological interventions. Notably, the SOC-7 recommends proceeding in controlled stages from less invasive to more invasive interventions. In addition, rather than expressing a consistent identity, Varian displayed rapid cycling of identities and names—from preferring to go by “Gabriel” to “Rowan” and identifying as “he/they” to settling on “they/them,” or what is known as “nonbinary” pronouns.
You would think Varian’s family context, existing neurodevelopmental and mental health issues, and rapidly cycling identity would clearly warrant the “more careful approach to consent and assent” that WPATH recommends for more complex clinical cases. Indeed, Varian’s psychologist determined that her judgment was “mildly impaired,” and his clinical notes indicate both “low intellectual and executive functioning,” which should have raised even more red flags.
According to Ryan’s reporting, the psychologist who wrote Varian’s mastectomy approval letter, Dr. Kenneth Einhorn, didn’t even believe it was indicated in her case, but he wrote the letter anyway because Varian “very much wanted the surgery.” While this might seem unusual, it’s consistent with the affirmative model’s ethos of matching treatment interventions to patient “goals for gender identity and expression.”
Although WPATH and other medical societies often present WPATH guidelines as the “standard of care”—at least until recently—it’s worth pointing out how radical the American “affirmative care” model is compared to the Dutch protocol, which pioneered pediatric gender medicine, and to the more conservative treatment approaches adopted by other European countries. For one, the Dutch protocol screened out youth with severe psychiatric issues and adolescent-onset dysphoria, which would automatically rule out many youth seeking interventions today. Second, the Dutch protocol was a pathway for “binary” medical transitions, whereas today many youth and young adults seek interventions for “nonbinary” identities, a cohort that lacks long-term outcome data, but which is often associated with poorer mental health overall than either binary trans-identified or “cisgender” peers. Similarly, in countries like Sweden, Finland and the U.K., psychotherapeutic interventions are the first line of treatment because of their more favorable risk-benefit ratio. Moreover, youth seeking treatment in these countries are often screened according to the stricter eligibility criteria established under the Dutch protocol.
In contrast, WPATH’s “standards of care” presupposes that gender-affirming treatments are effective interventions while sidestepping the ethical question of whether any minor has the genuine capacity to consent to these procedures. Because youth in recent years transitioned under WPATH’s more nebulous SOC-8 guidelines, I think we can expect to see even more flagrant malpractice cases in the future. While it is a welcome step that U.S. medical associations like the American Society of Plastic Surgeons are finally acknowledging the weak evidence base for pediatric gender medicine, the process of medical association and guideline reform is likely to be slow. In the interim, more adolescents are likely to be harmed by medical transition. Unfortunately, Varian and other young people are likely just the canaries in the coal mine.
