Open letter to the New Zealand Health Minister

WPATH and PATHA are not competent to guide New Zealand's approach to gender medicine.

Genspect’s Simon Tegg has written to Dr Shane Reti, New Zealand’s Health Minister summarising revelations from unsealed court documents and the implications for clinical guidelines in New Zealand.

3/7/2024

Tēnā koe Dr Reti,

I write to you with concerns regarding the “national gender-affirming care” guidelines contracted by Health NZ to the hybrid activist-professional organisation the Professional Association of Transgender Health Aotearoa (PATHA). PATHA is the local chapter of the international, but largely US-based, World Professional Association of Transgender Health (WPATH). Some members of PATHA are also members of WPATH – notably former PATHA President and current executive board member Dr Jamie Veale, who is also the current Secretary of WPATH.
The commissioning document from Health NZ states that the new national guidelines are to be drafted in line with the 2022 WPATH “Standards of Care” version 8 (SOC-8). 

Recent unsealed court [1] documents [2] in the USA, as reported in the New York Times and The Economist, confirm that WPATH is primarily an activist organisation rather than the scientific organisation it claims to be. WPATH produces guidelines and research to advance political goals and provide legal cover for the controversial medical practices of WPATH members and has little understanding of evidence-based medicine. These court documents, obtained through legal discovery, include internal communications between WPATH members and reveal several concerning issues:

1. Lack of consensus and evidence: Guideline authors expressed concerns about the lack of consensus and evidence for SOC-8 recommendations. One author stated, "My understanding is that a global consensus on ‘puberty blockers’ does not exist." [1]  When WPATH President Dr Marci Bowers was asked under deposition “whether reasonable people could conclude that there is not enough evidence to support the safety or clinical effectiveness of puberty blockers.” Bowers replied, “There's not enough high level evidence. Yes, you can – you can – you can say that”. [2]

2. Loosening standards: SOC-8 Authors worried that they had "loosened standards and lost some control." Some clinicians were providing "treatment on demand," and SOC-8 would further "open that up." [1]

3. Influence of social factors: Authors noted that "social factors" and immature decision-making could lead young people to mistakenly believe they are transgender. However, there was "no assessment tool" to differentiate between genuine and mistaken transgender status. [1]

4. Subservient to political and legal objectives: Guideline authors lobbied to tailor the language to influence courts and legislatures, even at the expense of scientific accuracy. One author admitted, "Our concerns…is [sic] that evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits." [2]

5. Conflicts of interest: The lead guideline author, Dr Coleman, acknowledged that "most participants in the SOC-8 process had financial and/or nonfinancial conflicts of interest." Dr Bowers admitted to making "more than a million dollars" from sex trait modification surgeries the previous year but found it “absurd” to disclose this while authoring a guideline recommending such surgeries.  SOC-8 readers were misled to believe that "no conflicts of interest among the authors were deemed significant or consequential." [2]

6. Suppression of systematic reviews: Guideline authors suppressed the publication of, or avoided commissioning, systematic reviews as reviews that found "little to no evidence"[3] would undermine WPATH’s political objectives. The lead of the mental health chapter testified that instead of relying on systematic reviews, they "used authors we were familiar with." Another author highlighted concerns about language indicating "insufficient evidence" or "limited data" as it would “empower” groups “trying to claim that gender-affirming interventions are experimental.” [2]

7. Political interference: In the final days before SOC-8 publication, age minimums for adolescent hormonal treatments and surgeries were removed due to external political pressure. WPATH had shared a draft with the Assistant Secretary for Health, Admiral Levine, who identifies as a woman. Levine argued that age minimums would undermine the administration's political goals. The American Academy of Pediatrics (AAP) also threatened to publicly oppose SOC-8 unless age minimums were removed. Despite their low regard for the AAP, WPATH complied, contradicting the wishes of guideline authors and the WPATH’s own formalised consensus process. WPATH later falsely claimed that the removal was due to a renewed focus on "individualized care." [2]

These revelations, alongside known deficiencies in PATHA’s existing guidelines [4], make WPATH or PATHA involvement in the Health NZ guidelines untenable. You must instruct Health NZ to cancel the contract and extinguish WPATH/PATHA influence in the NZ health system. 

Without your action, a young vulnerable group faces unacceptable risks of iatrogenic harm and the scientific and moral reputation of Health NZ, the Ministry of Health, and the coalition government will be compromised.

The previous Labour government had a well-meaning but misguided policy to “ensure our healthcare system is responsive to the needs of trans…and gender diverse people.” Interpreted broadly, this meant policymakers sought to expand access to puberty blockers and hormones to adolescents despite insufficient evidence for these interventions in routine use. OIA responses confirm that officials even discussed dropping psychological assessment or a diagnosis of gender dysphoria prior to an adolescent receiving puberty blockers or cross-sex hormones [5]. But this places the cart before the horse –it would be negligent to institute a ‘treatment on demand’ regime for adolescents without knowing for sure if treatments were beneficial and safe. Fortunately, the coalition government has emphasised the need for evidence-based policies and continued the Ministry’s evidence brief on puberty blockers (despite the inordinate and poorly explained delay in the evidence brief’s publication).  

***

I seek your reassurance that: 

1. PATHA or WPATH members have not attempted to influence, delay, or suppress the Ministry’s evidence brief and associated position statement. 

2. Health NZ advisors are on top of the situation and have advised you that the basis of the NZ clinical guidelines is the subject of a legal dispute in the USA.

 3. Any forthcoming guidance on the care of gender-questioning young people will not derive recommendations from WPATH or PATHA guidelines or research published in the WPATH-sponsored International Journal of Transgender Health. 

I also request under OIA the number  a) WPATH members and b) PATHA members who are also:

1) members of Health NZ’s Gender Affirming Primary Care Advisory Group, 

2) authors of the forthcoming national guidelines, or 

3) members of any third-party group that reviews or approves the above guidelines.   

Along with the membership totals of the above groups. I believe there is a strong public interest in understanding the affiliations of people in these positions.  

***

I appreciate your attention to this matter. The issues uncovered in the court documents cast serious doubt on the integrity of the guidelines developed by WPATH and PATHA. With the US Supreme Court recently agreeing to hear arguments on state bans of medical interventions for gender-questioning minors and more documents set to be unsealed, WPATH's future as an influential organisation is uncertain.

Given these concerns, it is crucial to reassess the Health NZ-PATHA relationship. The coalition government's focus on evidence-based policies is commendable, and it is important that scientific integrity is not compromised by political interference. 

---

Endnotes and Citations

[1] Boe v. Marshall - Exhibit 24: Appendix A to Supplemental Expert Report of

James Cantor, Ph.D. https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.591.24.pdf

[2] Boe v. Marshall: Defendant’s Motion for Summary Judgement

and Brief in Support https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.591.24.pdf

[3] The research team at Johns Hopkins University commissioned by WPATH did create a systematic review or reviews examining interventions for children and adolescents but found “little to no evidence”. [2].  Some completed reviews were never published e.g. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=135075 and https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=124845.

WPATH: “One paper from the Johns Hopkins University Team has recently been published online in the

International Journal of Transgender Health, whilst two papers have not received the green light to

be published. It is paramount that any publication based on the WPATH SOC8 data is thoroughly

scrutinized and reviewed to ensure that publication does not negatively affect the provision of

transgender healthcare in the broadest sense”
https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.560.17_1.pdf (p. 91)

A dozen systematic reviews were planned https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.560.18_1.pdf (p. 189-190)

[4] PATHA’s 2018 guidelines, the “Oliphant guidelines”, received the second lowest combined score (149/600) out of 21 quality assessed guidelines in a systematic review https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326499. The Oliphant guidelines received scores of 12/100 for “Rigour of development” and 0/100 for “Editorial independence” subscales.

[5]  HR20210124: Improving the health system's responsiveness to transgender, non-binary and intersex people; paragraph 29