Why WPATH Chose the Path to Disaster

How trans activism captured gender medicine

In the 1990s, behind closed doors and far from public view, the foundation was laid for an extraordinary medical scandal. It all started with a bizarre idea: that being transgender is a natural variation of human existence that just happens to require drastic medical treatments. There was no truth to this idea. Yet it was able to travel from the inner world of a tiny number of people whose whole being was fused with it, into pseudo-legal blueprints, into medical protocols, and then, catastrophically, into mainstream culture and the minds of untold numbers of vulnerable people.

In those early days, the group now known as the World Professional Association for Transgender Health (WPATH) played a pivotal role in the idea’s remarkable journey. WPATH not only allowed itself to be captured by the idea, but elevated it to the guiding principle of the entire field of gender medicine. The result was the scandal of gender-affirming care.

The Idea Gathers Strength

The story begins in the 1980s, in the earliest days of the modern transgender rights movement. Dr. Paul McHugh had only recently shut down John Money’s gender clinic at Hopkins, an event that resulted in a cascade of similar closures at university-based hospitals. The US Department of Health and Human Services had deemed the interventions experimental and pulled Medicaid funding, and at the time, the sex change experiment appeared to be drawing to a close.

In reality, it had barely even begun.

Because while the clinics had been shuttered, the idea that some people are transgender and require medical treatment was only gaining strength. And a small group of dedicated activists set about building a rights movement with the primary goal of restoring access to hormones and surgeries.

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While other groups were already working toward the same goal, the pivotal meeting came on August 28, 1992, when a grassroots group of activists gathered in Houston, Texas, for the first International Conference on Transgender Law and Employment Policy (ICTLEP). The lawyers, human rights experts, entrepreneurs, and academics who organized and spoke at the event all had one thing in common: they identified as transgender. And what that meant to them would shape everything that followed.

At the time of the 1992 conference, “transgendered” was defined as people “who were born of one sex, yet have a definite opposite gender identity.” A year later, “transsexualism” was defined as the “desire to change the expression of one’s gender identity [that] is not in itself a medical illness or mental disorder.” In other words, the architects of modern trans activism understood their desire to live as the opposite sex and medically alter their bodies not as a disorder, but as an authentic expression of healthy identity.

The trouble was that this understanding lacked insight. And a long-neglected psychiatric concept—the overvalued belief—was to provide the framework for understanding their false conviction.

First described as an overvalued idea by psychiatrist Carl Wernicke in 1892, the concept refers to a mental disorder organized around a single, all-consuming fixation that dominates an individual’s thinking and drives pathological behavior. Perhaps the best-known example is anorexia nervosa, in which the sufferer believes she is fat, a conviction that drives her to restrict food to the point of emaciation. Although its expression varies, the core conviction of transgender ideation can be simplified into: I am trans; my transgender identity is healthy and not a mental disorder, and I need to medically alter my sex characteristics.

An essential feature of an overvalued belief is that it is ego-syntonic, meaning individuals experience it as a true and authentic expression of their deepest nature and therefore do not regard themselves as mentally ill. As a consequence, sufferers typically respond with intense anger to the suggestion that their belief is psychiatric in origin and become deeply frustrated with anyone they perceive as obstructing their quest to act on their convictions.

Laying the Groundwork

In Houston, the task at hand was turning this deeply held conviction into a civil rights movement. It was Texas attorney Phyllis Frye who had the idea to bring like-minded people together to develop “strategies for progressive changes.” Out of those meetings came The International Bill of Gender Rights, declaring that “all human beings have the right to declare their own gender identity,” along with the “right to change their bodies cosmetically, chemically, or surgically, to express a self-defined gender identity.” It also declared that transgender individuals “should not be subject to involuntary psychiatric diagnosis or treatment.”

The International Bill of Gender Rights embedded the core belief held by this tiny group within a pseudo-legal blueprint, transforming a private conviction into the foundation of a coordinated international civil rights project. In the decades to come, the framework laid out in Texas would form the scaffolding of the entire transgender movement.

WPATH as the Perpetual Villain

In an interesting twist, WPATH—the villain of today’s era—was seen as the villain then too, albeit for opposite reasons. While today many who consider gender-affirming care to be a medical scandal lay the blame on WPATH for removing guardrails and advocating for an affirmative, medicalization-on-demand approach to treating transgender identities, back in the 1990s, when WPATH was known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA), it was the group’s caution and safeguarding that drew the ire from the newly formed transgender movement.

This is evident in the footnote of the Health Law Standards of Care drawn up in 1993 by trans-identified entrepreneur Martine Rothblatt, which states that the document was developed “in the wake of widespread dissatisfaction by many in the transgendered community with the Harry Benjamin Standards of Care.” This dissatisfaction stemmed from HBIGDA classifying transgender identities as a psychiatric disorder and the Standards of Care requiring two referral letters from mental health professionals before an individual could undergo surgeries.

Principle 1 of Rothblatt’s Standards of Care declared:

Transsexualism is an ancient and persistent part of human experience and is not in itself a medical illness or mental disorder. Transsexualism is a desire to change the expression of one’s gender identity.

In other words, the core belief at the heart of the disorder. Rothblatt’s Principle 2 then reframes the pathological desire as a fundamental human right:

Persons have the right to express their gender identity through changes to their physical appearance, including the use of hormones and reconstructive surgery.

While presenting at the 1993 ICTLEP Houston gathering, Rothblatt revealed plans “to get these standards of care printed and published” before HBIGDA’s upcoming meeting, and to be “in their face” at the event.

Swap in anorexia and the absurdity of what Rothblatt and the Houston meetings were demanding becomes glaringly obvious. The anorexic experiences her belief as ego-syntonic, as in, she truly believes she is fat, and this belief propels her to starve herself. She also reacts angrily to loved ones or healthcare professionals who try to force her to eat, obstructing her quest to lose weight.

Now imagine a group of dedicated ProAna activists gathered in Houston and drew up their own Standards of Care. Principle 1 declares that:

Anorexia is an ancient and persistent part of human experience and is not in and of itself a medical illness or a mental disorder. Anorexia is a desire to change the expression of one’s body weight identity.

Principle 2 of the Standards of Care for Anorexics reads:

Persons have the right to express their anorexic identities through changes to their physical appearance, including through the use of GLP-1 receptor agonists and liposuction.

It is impossible to imagine a world in which eating disorder experts and medical associations would accept this as true and bow to their demands, and yet, that is precisely what happened with the field of gender medicine.

HBIGDA Flings Open the Doors

In the mid-1990s, a resourceful trans-identified female activist named Jamison Green began thinking seriously about how to get hormones and surgeries covered by insurance and expand access to medical treatment for the transgender community. After a friend told Green of the existence of HBIGDA, she obtained a copy of the group’s Standards of Care (then SOC4). Dissatisfied with what she found, Green resolved to get “trans people…more involved in the establishing of criteria that both defined us and influenced our health.”

Green discovered that HBIGDA would be holding its annual conference in Vancouver in 1997 and decided to attend. In a 2022 essay, she describes a historically significant moment that unfolded during the event.

While SOC5 chair Dr. Stephen Levine was onstage outlining the upcoming changes in the Standards of Care, protestors began furiously banging on the auditorium doors, alarming those gathered inside. As Green recalls, the “pounding and yelling was frightening, especially for those seated in the back.” This makes the reaction of then-president Richard Green all the more puzzling. For instead of calling security and having the aggressive protestors removed, Green reportedly said: “It’s all right; let them in.”

No one could have staged a more perfect real-world enactment of what was happening at the time to HBIGDA itself.

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As a result of this disruption, Jamison Green was included as one of two activist consultants on SOC5, though none of her recommendations actually made it into the final document. Shortly after its publication, however, Richard Green, unhappy with Levine’s insistence on requiring two referral letters before surgery, commissioned SOC6. Published just three years later, it required only one referral letter, and this time, many of Jamison Green’s recommendations were included.

With that, the desires of trans-identified people officially began to shape HBIGDA’s Standards of Care, and the march towards depsychopathologization was officially underway.

Levine left HBIGDA just a few short years later, after attending the group’s 2001 conference and witnessing an audience filled with “cross-dressed men” who booed whenever they heard something they didn’t like. Levine understood with striking clarity what these events signified, later recalling that “what he had thought was a scientific organization was now an advocacy group”— a transformation that, in his view, meant “that science was secondary to these poor, suffering people needing to have exactly what they want.”

Around the same time, another very telling ruckus was unfolding. In 2003, Professor Michael Bailey’s book The Man Who Would Be Queen was published, popularising Dr. Ray Blanchard’s concept of autogynephilia that he had introduced in a 1989 paper. In short, Blanchard’s typology separates individuals who pursue hormonal and surgical interventions into two categories: extremely gender-nonconforming homosexuals, whom Blanchard termed homosexual transsexuals (HSTS), and autogynephilic men — heterosexual males with a paraphilia involving an erotic fixation on the self as female.

While Blanchard’s work remained confined to academic journals and received minimal pushback, Bailey’s book ignited furious backlash from the trans activist community, and three trans-identified males embarked upon a vicious campaign to destroy him both professionally and personally. When viewed in the context of the political maneuvering underway at the time, the intensity of this response becomes easier to understand, though of course it in no way justifies their actions.

In the words of Lynn Conway — one of the three persecutors — Blanchard’s typology made “a sweeping claim of having discovered the cause of transsexualism” and “eliminated inner gender identity or gendered feelings (GID) as factors or mechanisms in transsexualism, replacing them with a model of transsexualism as a pathological male sexual disorder.”

Put simply: Bailey’s book popularized the idea that trans was a pathology right at the very moment that activists were burying and forbidding mention of that very framing. And so, Bailey had to be destroyed.

Few things better illustrate HBIGDA’s complete capture by trans activists than the organization’s response to the attacks on Bailey. The Board of Directors sided with his critics, dismissing the book as “poorly referenced” and claiming that it did not reflect “the social and scientific literature that exists on transsexual people.” HBIGDA emphasized that “trust and mutual respect between the scientific and transgender communities is essential,” and warned that Bailey’s book risked damaging that relationship.

Eli Coleman, who had been HBIGDA president from 1999 to 2003, and was destined to be chair of the group’s infamous Standards of Care 8 (SOC8) published in 2022, even went so far as to thank one of Bailey’s persecutors for bringing forth the concerns of the transgender community. In protest, Blanchard then followed in Levine’s footsteps and resigned from the organization, and HBIGDA lost another scientific mind.

Now consider for a moment what building trust with the transgender community actually means. Remember that a key characteristic of individuals in the grips of an overvalued belief is intolerance of the suggestion that the issue is psychiatric in origin. Meaning, the only way to earn the trust of this group of patients is to deny the reality of their mental disorder. When HBIGDA elevated building trust with the transgender community as its priority, it had to sacrifice reality, and in the process, all psychiatric guardrails.

The Greatest Rebrand in History

In 2006, at a HBIGDA meeting in New York City, board members came up with a rebrand for the organization that would put most marketing executives to shame. Gone was the Harry Benjamin International Gender Dysphoria Association, and in came the World Professional Association for Transgender Health (WPATH). In one stroke, an obscure, fringe affiliation of activists and clinicians became a respectable, professional, international medical association. But there was more to the name change than just the new veneer of respectability. The move was another crucial step towards depsychopathologization — replacing the treatment of gender dysphoria with a focus on transgender health.

This stroke of genius sprang from the mind of Jamison Green, who later recalled suggesting that the organization stop “implying that our focus was a disease condition, and state unequivocally that our focus is transgender health, not a disorder diagnosis.” At the helm of WPATH at the time of its miraculous rebirth was trans-identified female law professor Stephen Whittle — a prominent activist who had been present at those early meetings in Houston and a staunch supporter of depsychopathologization. In 2008, newly minted WPATH’s first order of business was to produce a statement declaring all hormonal and surgical interventions “medically necessary” for legal and insurance purposes — again the work of Jamison Green, such a key figure in shaping the direction the field of gender medicine has traveled.

Official Victory

Then, just 13 years after trans activists stormed the HBIGDA conference in Vancouver “filling every available space, cheering [and] feeling victorious,” their victory was complete. In May, 2010, WPATH issued its depsychopathologization statement, “urging the de-psychopathologisation of gender variance worldwide.”

In deliberately obfuscating language, WPATH declared that the “expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative.” However, don’t let the circumlocution befuddle you. Stripped of the jargon, the statement was really saying that identifying as the opposite sex and desiring the medical alteration of healthy sex characteristics is not pathological. The overvalued belief held by the activists who had gathered in Houston — however false and lacking in insight — had now become the guiding principle of WPATH.

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From this point forth, anyone suffering from this mental disorder cannot get the treatment they need, because the medical and mental health worlds, and in a few short years wider society too, are forbidden from naming, recognizing, or even acknowledging the existence of the disorder. With the victory of depsychopathologization, validation and collusion became the only permissible responses. A dream come true for those in the grips of the belief, but also the makings of a medical disaster.

The Road Taken

In those early days, the trajectory of gender medicine was altered by one pivotal choice. In the late 1990s, HBIGDA found itself at a fork in the road. One path required defending scientific principles, maintaining open debate, and upholding ethical standards. The other involved throwing caution to the wind and embarking on an ideological quest led by militant activists.

HBIGDA chose the path of least resistance, opting to give a determined and forceful group of patients precisely what their disorder demanded. And it’s not difficult to understand why that choice was so alluring. It undoubtedly felt compassionate and progressive, infused with the cultural zeal of the era and the intoxicating sense of being on the right side of history.

Whereas the alternative path was far more difficult. It meant keeping the doors barricaded and saying no to patients in genuine distress—patients utterly convinced that medical body modification was the only solution to their suffering, and who, in some cases, threatened self-harm when their demands were not met. Holding that line required a degree of courage and resolve that HBIGDA, collectively, simply did not possess.

No one inside HBIGDA appears to have considered the consequences of the path they were choosing. Apparently caught up in the moral righteousness of the moment, they did not stop to ask what might happen when an entire medical field allowed a political movement to guide its practices. The technological environment that would later trigger an explosion in patients did not yet exist: the internet was still in its infancy, and smartphones and social media — the eventual superspreading environment that would turbocharge the medical scandal — were still over a decade away.

Yet one person present at those first Houston meetings did have more than an inkling of what was to come.

In his 1996 book The Apartheid of Sex, Rothblatt described a futuristic world of “cyberspace” where people could “readily pretend to be a different sex.” He foresaw that digital environments would disconnect people from their physical bodies, allowing them to adopt a new name and move between sexual identities with the same ease that computer graphics could transform one image into another. As he put it, cyberspace would allow a person to “MorF (male or female) one sex into any other.”

Understandably, almost no one at the time took Rothblatt seriously. Yet the world he envisioned did, in fact, become reality.

When legions of lost young people began congregating in the online world Rothblatt had imagined, many encountered the enticing idea that those early Houston meetings had unleashed: that trans was just another way to be a person. This idea offered not only an explanation for their struggles — a ready-made answer to feelings of alienation, confusion, and distress — but also a magical solution: they could leave behind their shameful old selves and become someone new. In that digital environment, they would disconnect from their sex with precisely the ease Rothblatt had predicted, reinventing themselves through new names, pronouns, and avatars. And when these digital identities began spilling over into the real world, the pursuit of medical embodiment inevitably followed.

Tragically, thanks to Rothblatt and his fellow Houston visionaries, and the activists who swarmed HBIGDA and the weak leadership that allowed them to take over, when those throngs began flooding the waiting rooms of gender clinics, only collusion with the disorder was permitted, and there were no guardrails left to stop them in their tracks.

And so, the stage was set for a medical catastrophe.

Mia Hughes is the author of The WPATH Files, Director of Genspect Canada, Director of Policy and Research at Genspect, and co-host of the Beyond Gender podcast with Dr Stella O’Malley.

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