by Kelley Winters, Ph.D.

Preliminary Draft

Earlier this week, the World Professional Association for Transgender Health (WPATH) held its biennial election for officers of its Executive Committee and directors-at-large. Members were not allowed to vote for individual candidates for the offices of President Elect, Secretary, and Treasurer but were instead instructed to vote “Yes or No” on a slate of candidates nominated by a small committee in the inner sanctum of WPATH politic. Traditionally, the nomination for Treasurer is viewed with a lot of anticipation by members, as this office has often been the springboard to the presidency. For example, the current Treasurer, Dr. Walter Pierre Bouman, is the nominee for President Elect on the 2018 slate.

Curiously, the nominee for Treasurer on the 2018 slate is somewhat new to health policy development at WPATH and is not listed as participating in the current Standards of Care, Version 7 (SOC7). Dr. Baudewijntje Kreukels is an Associate Professor of Psychology at VU University Medical Center, Amsterdam. She is a researcher in neuroimaging and other study of trans people, who has served as editor-in-chief on a Dutch journal on Neuroscience. She was nominated, not competitively elected, to the WPATH board as part of a packaged slate in 2016.

Most of Dr. Kreukels’ published literature is reasonably respectful of trans people in tone and terminology. However, any pretense of politeness and objectivity comes to an abrupt halt in her most impactful paper, coauthored with Drs. Kenneth Zucker and Anne Lawrence in the 2016 Annual Review of Clinical Psychology. Titled, “Gender Dysphoria in Adults,” Kreukels’ paper misgenders trans women as “males” and “men,” and trans men as “females” and “women.” Archaic “FtM” and “MtF” terms are used overwhelmingly as nouns. Trans women are explicitly denied legitimacy as women, for example: “MtFs differed from those of men and, partly, also of women” (p. 233). Straight trans women and their partners are misgendered as “homosexual,” as are straight trans men and their partners.

The paper misrepresents a 2011 Swedish study by Dr. Cecilia Dhejne on the mental health of trans people who have received transition related surgical care–

The 2011 study, discussed previously, described the greatly elevated prevalence of comorbid psychopathology, death by suicide, and suicide attempts in the cohort of clients who underwent SRS between 1973 and 2013. (p. 237)

This paper follows the example of anti-trans extremist, Dr. Paul McHugh, in suggesting that morbidity and suicidality are “greatly elevated” after surgical care. Kreukel and her coauthors imply that Dr. Dhejne had causally linked transition surgeries with suicide. However, Dr. Dhejne has strongly refuted this as misrepresentation–

People who misuse the study always omit the fact that the study clearly states that it is not an evaluation of gender dysphoria treatment. If we look at the literature, we find that several recent studies conclude that WPATH Standards of Care compliant treatment decrease gender dysphoria and improves mental health.

In the same interview with TransAdvocate founder, Cristan Williams, Dr. Dhejne clarified–

It is therefore important to note that the current study is only informative with respect to transsexual persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.

Indeed. In science, co-occurrence is not causation.

The authors are sharply criticial of affirming policy changes in recent revisions of the WPATH Standards of Care. For instance, Dr. Kreukels and her coauthors decry the SOC7 statement that “Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth…is no longer considered ethical.” They reassert support for gender-conversion psychotherapies that are now illegal for children in numerous jurisdictions in the U.S. and Canada. Dr. Zucker previously headed a program of gender-conversion psychotherapy and research on trans and gender non-conforming children at the Toronto Centre for Addiction and Mental Health (CAMH, formerly known as the Clarke Institute). His program was famously closed in 2015 by CAMH management. The authors speculate that, “perhaps psychotherapy could facilitate such remission—or a reduction in GD symptoms, with greater congruence between gender identity and expression and assigned sex…” (p. 237)

The authors complain that SOC7 that no longer promotes discredited “autogynephilia” or “late onset” stereotypes that delegitimize trans women based on their sexual orientation. In 1989, CAMH patriarch, Dr. Raymond Blanchard, speculated that “all,” not some, but “All gender dysphoric males who are not sexually oriented toward men are instead sexually oriented toward the thought or image of themselves as women.” In other words, Blanchard and his followers insist that gender dysphoria in the majority of adult trans women is nothing more than a sexual fetish, unrelated to inner gender identity. While this myth has been mostly abandoned in clinical practice and mainstream policy, it remains a mainstay of propaganda from anti-trans extremist groups on both the political right and left. Yet Dr. Kreukels and her coauthors condemn the removal of Blanchard’s axiom from the SOC7 as “intellectual erasure” (p. 221).

Most troubling, the paper reasserts the discredited 80% “desistance” myth about gender dysphoric children, which demands that the vast majority of young children distressed by their sex characteristics or birth-assigned gender roles will spontaneously “desist” by puberty to become cisgender adolescents and adults. This stereotype, rooted in substantially flawed studies from Zucker’s Clarke Institute/CAMH and Kreukels’ own VU University Medical Center in the 1990s and early 2000s, is often cited by theo-political extremist groups to deny basic civil rights and education access to transgender children. Though strongly opposed by many clinicians and the WPATH International Advisory Panel at time of publication, the 80% “desistance” axiom is uncritically stated as fact in the current SOC7. There is broad community and provider support in removing it from the next revision.

To their credit and my surprise, the authors seem supportive of changes in the SOC6 and 7 that elevate the role of medical professionals in providing access to hormonal transition care, without the absolute necessity of gatekeeping by mental health clinicians. They acknowledge that this informed consent model serves to reduce harm associated with medically unsupervised hormone use (p. 237). Moreover, they question (p. 238) the SOC7 requirement of at least 12-months of full-time life in the experienced gender role before access to corrective genital surgeries—a question that Dr. Lawrence has raised, seemingly paradoxically, for some years. There is growing support for more flexibility on this requirement in the SOC8.

On balance, however, this paper is extremely troubling in its disrespect for the legitimacy of trans people in our authentic gender roles and its promotion of archaic stereotypes that are scientifically capricious and socially punitive. Though purporting to provide “greater understanding of the research and clinical issues” (p. 240), this paper has every appearance of a manifesto targeting the WPATH leadership. The authors are clearly calling for WPATH to roll back the clock and reverse many crucial elements of forward progress in the Standards of Care.

As the presumptive WPATH Treasurer and heir-apparent to its presidency, Dr. Kreukels has a lot of explaining to do about the bias and stereotyping in this paper that bears her name. Furthermore, the current WPATH President, Dr. Gail Knudson, owes an explanation to her membership and my trans community about the intentions behind Dr. Kreukels’ nomination and the back-room practices that deny members the opportunity to vote for their own officers.

The very lives of trans people hang on policy decisions that are driven by the WPATH President and Executive Committee. With great power comes great responsibility. Accountability and transparency should follow close behind.