New transgender guidelines no longer include age thresholds for gender-affirming surgery

An influential updated international guide on transgender health that no longer includes minimum age thresholds for “gender-affirming surgery” such as double mastectomies and operations on the genitals is being studied by the Health Service Executive (HSE).

However, the Department of Health told The Irish Times there would be no change in the Irish model of care “pending the outcome” of discussions with the HSE about the new recommendations.

The updated edition of the Standards of Care of the US-based World Professional Association of Transgender Healthcare (WPATH) initially contained recommended age thresholds for surgical and pharmaceutical sex change treatments.

These included 14 years of age for the administration of cross-sex hormones, 15 years for “chest masculinisation” (mastectomies), and 17 for metoidioplasty (a type of penis creation), orchidectomy (the removal of the testicles), vaginoplasty (the construction of a vagina) and hysterectomy (the removal of the womb).

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However, the updated WPATH edition published earlier this month was amended hours after it was posted online, with WPATH saying the age thresholds originally included were being removed as they had been published “in error”. A request for a comment from WPATH late last week has met with no response.

The WPATH guidelines are globally influential, and its standards of care are cited in the programme for government. The HSE cited the WPATH guidelines last year in an advertisement for a child psychiatrist to work in the child and adolescent gender service, which sees patients up to the age of 17.

The new WPATH document is the eight edition of the standards. In the seventh edition, published in 2011, the age threshold for significant medical interventions for children and adolescents was the “age of majority” in the jurisdiction concerned.

The new edition for the first time includes a chapter on eunuchs, who WPATH now says can fall within the “gender diverse umbrella”.

“As with other gender diverse individuals, eunuchs may also seek castration to better align their bodies with their gender identity,” according to the document.

In its programme for government, the Coalition said it would “create and implement a general health policy for trans people, based on a best practice model for care, in line with the World Professional Association of Transgender Healthcare [WPATH]” .

In an advertisement last year looking for a child psychiatrist to work with young people suffering from gender distress, the HSE said the service would, among other matters, be delivered in line with “national and international guidelines for the care of children and adolescents with gender identity issues such as the WPATH Standards of Care”. The post remains unfilled.

In a statement to The Irish Times, the HSE said guidelines on gender care were constantly evolving and new standards such as those from WPATH “will be studied by the expert teams and any recommendations to change the model of care, if made, will be discussed with the HSE and the Department of Health”.

The Department of Health said it was in discussions with the HSE on the updated WPATH standards and there would be no change to the “Irish model of care” pending the outcome of these talks.

There have long been sharply divergent views between the Irish adult and youth services in relation to the assessment of patients suffering gender distress, with the adult service being critical of the “affirmation” approach used in the child and adolescent service.

Dr Paul Moran, a psychiatrist with the adult national gender service, told The Irish Times he and his colleagues had for years been urging the HSE and the Department of Health to drop their support for the WPATH model, which they believe is unsafe and which they do not implement in the adult service.

He said a significant number of the patients he sees who have graduated from the youth to the adult gender service for age reasons were autistic, with “unclear gender identity”.

“Whereas a few years ago most patients presenting were suitable and ready for gender-affirming medical interventions, now it’s the opposite.”

Dr Moran is not a member of WPATH, which he said was heavily influenced by gender activists as against healthcare professionals. In submissions to the Department of Health in 2018, when a briefing was being prepared for the then taoiseach, Dr Moran said the WPATH type of approach had in the past in Ireland been associated with “severe adverse clinical outcomes for patients”.

Comment was sought from Transgender Equality Network Ireland and Belong To, both of which lobby for transgender healthcare services, but no response was received at the time of going to press. Both groups have frequently criticised the lengthy delays that exist for those trying to enter the youth and adult services.