WPATH 2024: Part 1

We’re honored to be reposting Cal Horton’s wonderful post on attending WPATH 2024 in Lisbon. Please check out the original on their blog.

At the end of 4 days of trans health presentations from researchers, clinicians and community advocates from across (parts of) the world, I wanted to capture some of my key learnings and reflections. The conference took place the last week of September, in Lisbon, Portugal. This is my first WPATH (a conference of the World Professional Association for Transgender Health). A majority of trans communities have no access to WPATH information, yet WPATH learning is important to many trans people and families. I’ve always appreciated those (especially Ruth Pearce) who try to make conference information available to those unable to attend. I note the significant barriers to attendance for those without an employer or institution to fund expensive attendance fees and travel, to those with disabilities or caring responsibilities unable to travel, for those without a visa to come to Europe, to those facing other barriers to attendance.

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Overall vibe

The overall vibe was better than I had expected, although my expectations were drawn from hearing really poor experiences at past WPATH conferences. I found overall the tone of trans positivity, depathologisation, treating trans people as equals, centring research and healthcare ethics, was better than I had expected. However, there were still a portion of content and conversations where biases were clearly on display. I particularly noticed these biases in the very frequent exclusion of non-binary existence, on the continued pathologisation, mistreatment and exoticisation of trans children, and on a very significant domination of a US and white perspective, with notably limited representation from global majority populations. I gather only 3 attendees were from Africa (out of 1,445 registered in-person attendees). I also am scratching my head to think if there was even a solitary reference to the experiences of trans children in care in the presentations I attended – I don’t think there was.

The event had a trans chill out room where trans attendees could step away from the main event to decompress and reflect. It was noticeable that few trans attendees spent time there in the first days of the conference, with the fullness of the room growing over time, as trans researchers, clinicians and advocates encountered more challenging content and interactions. On the third day I heard one person reflect that despite WPATH improvements, it is noticeable just how many trans people are sat in the trans space burnt out by negative engagements by day three of four. I myself had a number of negative and hostile encounters, and a number of presentations that I could not sit through, finding some content taxing or upsetting, particularly where content demonstrated abusive clinical or research practices towards trans children. There were a number of other challenges at the conference, with no encouragement of sharing pronouns (apparently pronoun ribbons were lost in shipping), not being able to find gender neutral toilets on the first evening, and apparently some staff policing of toilet usage which was rather surprising in a trans health conference.

There were also a large number of encounters and presentations that were an absolute delight. I met a huge number of people from across different countries and disciplines who deeply care for improving equality and justice for trans people of all ages and situations. I heard some research that shows where we should be in terms of ensuring research and healthcare is centring the rights and needs of trans communities. One clear highlight was an opportunity to connect with TPATH, the trans professional association for transgender health, including an opportunity to connect with some Portuguese trans folks who were not able to attend the conference.

 Session structure

 The session included plenary speeches, symposia, oral abstracts and posters. I will write about each in turn.

Plenary sessions.

On each day there were two plenary sessions, that were hour long speeches to the full audience, from one or two speakers, with a moderator. The plenary speakers were appointed by the WPATH president. Three were related to surgery, which I won’t engage with here as its not an area I focus on or know a lot about. A broader reflection was that at times the plenaries overall were a source of pathologisation, erasure of non-binary people, dehumanisation, exoticisation, and demonstration of clinical control over trans communities. There were several sessions where, if one had a bingo card of common areas of biases and indicators of cis-supremacy, one might have ticked off many exemplars. The speakers also privileged a white, cis, US/European, abled, and clinical position. Of the plenary sessions, the one I enjoyed the most was the opening plenary, delivered capably by an American, the US state representative for Montana, Zooey Zephyr. It was a powerful and moving speech, capturing the challenges that we currently face. I particularly resonated by the words (that I am paraphrasing), that when anti-trans laws are passed, when communities face state persecution, the harm comes severe and fast, whilst processes to overturn such harms are drawn-out and slow. Those words certainly resonated with my experience in the UK, where the harms of recent criminalisation of adolescent healthcare has indeed been severe and fast. The speech and presentation was excellent, but very US centred for an opening plenary. I wouldn’t expect anything less than US centred content from a US state representative, so this US centring is more a question for WPATH leadership than for the presenter. Why would a WPATH opening plenary would be so US centred. The tendency for WPATH (the World association) to act as US-path on holiday does appear to continue to be on display. However, this opening plenary was at least very strongly trans-positive, centring trans rights, calling attention to the abuse, control and persecution of trans communities, including trans children. The other plenaries alas did not all maintain this important commitment on trans-positivity, rights and justice. Several centred a clinical perspective grounded in assumptions of clinician control over trans lives. The plenary on trans children was particularly problematic and disappointing, presenting to a wide audience some older concepts and research that are problematic and outdated, centring and justifying clinical control over trans children. There were times across the plenaries where trans community and service user voice and perspectives were absent, with speakers prioritising a cis, adult, white, global North, clinician perspective. 

I was disappointed to have the plenary on puberty blockers delivered by stakeholder from the Dutch clinics, whose model does not centre trans child and adolescent rights. The presentation itself summarised older research (some of which is problematic) and failed to update the audience on newer research findings from other countries. It was a really lost opportunity to update general attendees on the most up-to-date research on puberty blockers. I also wish we could hear more from Dutch trans communities and service users, particularly child service users, on the Dutch approach. My own research has centred the experiences of service users in the English Children’s Gender Service, which aimed to replicate the Dutch model. My own experience and my research with that service has demonstrated widespread clinical abuse and harms to trans children in that service. (My research, including on experiences in gender clinics, experiences of childhood social transition, experiences with puberty blockers, and on pathologisation and cis-supremacy in healthcare can all be found here).

I hope the next WPATH can better centre child rights, trans rights, an ethics of depathologisation and equality in future plenary sessions, ensuring that any presentations from clinicians centre some fairly basic ethical commitments.

Parallel sessions

Across the conference there were 14 different sessions (hour long time slots), during which attendees had to choose between 5 parallel options, 3 of which were usually symposia and 2 of which were oral abstract sessions. That meant there were a total of 70 hour long sessions, that we could attend only 14 of. The sessions we could attend are recorded and available to watch on catch-up, and I’ll certainly check in on some of the ones I missed in coming weeks. Here I’ll comment on some of the symposia of oral abstract sessions that I attended.

Symposia

On being a target

There was an excellent session on trans researchers being a target of hate and harassment. Unsurprisingly it featured two UK researchers, talking about the amount of targeted hate that comes with being a trans researcher in the UK. We need to find better ways of supporting trans researchers. And we need our institutions to step up, both to protect trans researchers from external abuse, and to ensure research spaces and universities are actually safe from organised transphobia.

Trauma-informed approaches to care

This session talked about trauma informed approaches. I’ve not heard much discussion of this before, and certainly not on how to ensure child and adolescent care is trauma informed. I noted particularly the discussion on how certain mindfulness techniques are inappropriate and triggering rather than relaxing for those living with trauma. I recognised this in myself (I find mindfulness unbearable), but wasn’t aware this was a more general phenomenon. There has been a big recent focus on mindfulness in schools in the UK, and I wonder how this is being experienced by children living with trauma, which will include a lot of trans children.

Evolution of gender expression care

This session focused on the support that trans people, and especially younger trans children, may benefit from in areas of their life not related to medical care. The presenters are including the term ‘gender expression’ care to capture support with social transition, gender expression and finding gender joy, as distinct from and running parallel to medical transition support.

New long-term research on adolescent gender-affirming medical care

This session was excellent, with three important presentations from the US, from Diane Chen, Laura Kuper and Kristina Olson. I will write up some more detail on these three presentations soon as they are very timely and relevant. Watch this space.

Preserving evidence-based trans healthcare for adolescents in Europe and North America

This included presentations on how clinicians are navigating care restrictions and challenges to care. It included a focus on the UK, USA, Croatia, as well as discussion on upcoming guidelines from Switzerland, Germany and Austria. It included discussions of clinical care on the defensive, and how to ensure services that are under attack are shifted to the most defensible positions. I would have liked a more significant focus on how to ensure ethical principles and child rights within services that are under attack. I would have liked more explicit discussion of the impacts on trans children of a shift into defensive practice, which often includes bringing in or maintaining approaches that are not in a child’s best interest. I would have liked more consideration of how to ensure child rights and prioritised while operating under defensive practice, and more explicit acknowledgement of the harms, and more proactive work to ameliorate such harms. I’d also like more discussion of how a shift to defensive practice can provide a cover for coercive and harmful practices beyond what might be 100% essential. And how those shifting to defensive practice need to be more rather than less accountable to criticism of their practices. We also need to consider whether shifting to the most defensible positions actually appeases or reduces criticism from trans-hostile actors – in the UK this was certainly not the case, every shift to the defensive led to more attacks on care. I think a ethical and rights based defense of care is stronger than any effort at appeasement. (This session clashed with another session on “Research-based, ethical, lifesaving: findings from a long-term satisfaction study on pediatric gender affirming care” that I hope to catch up on later.

Centring Gender Diverse Young Children’s Voices and Experiences in Clinical Care and Research

A tool developed by Zucker (1977) was presented, with discussion of its cisnormative flaws and failings. The presentation then talked about experience of modern research using this tool. I don’t understand using an outdated and inappropriate tool developed by Zucker with modern trans children. I didn’t stay for the full presentation so perhaps I misunderstood something. I worry about research practices that do not centre trans children’s well-being and do not protect from research related harms. In my experience every question asked to a trans child by a professional, of any type, is an example of that child being treated differently. Children notice when their identity is treated differently. They notice when they are being studied. All research needs to consider the potential for children feeling shame. I returned to the session later for a discussion on the use of dolls to help children display their gender. I was probably not in the best head space for the doll discussion. Again, I was prompted to ask myself how many cis children are asked to dress a doll in a meaningful outfit under adult stranger/professional scrutiny. How do those trans children feel. I’m sure this can be done in a really positive way, and I don’t doubt the researchers presenting who seemed lovely do this in a positive way. But there was also suggestion of sharing this approach and these dolls much more widely. I didn’t stay for the whole session. I hope there was also significant discussion on the many trans children who do not want to dress dolls while under adult scrutiny, on the children who don’t want to be treated differently just because they are trans. I hope there was discussion on the ways in which a doll dressing exercise can be done really badly by the wrong facilitator, how it could be experienced by a child as being a subject of adult curiousity of how different and weird they are compared to their siblings and peers who are not asked to do this task. I worry about any initiative that en masse treats trans children in a different way to cis children, and anything that is not individually determined and centred. The younger children who I have known most closely would have hated being asked to dress a doll to present themselves, especially at a point in time early in transition where their clothing and expression is being most extremely scrutinised and judged and commented on by those around them. For all of these tools, I guess the context and the intent is really important. In a really safe environment, where children are not already feeling hostility and judgement and shame, perhaps a doll dressing challenge could be a source of gender joy for some children. How do we know which environments are safe for this? How do we know which children will enjoy it? How do we offer this as one of very many, many, fun activities, and ensure children do not feel compelled to engage as part of defending their existence to the adults around them. Given the choice of a coordinated doll dressing activity and a game of tag or watching a movie, a majority of the trans kids I know best would choose tag or watching a movie. In my experience, younger trans children, especially those early in transition, are very very tuned in to any areas of their life where they are treated differently or scrutinised. How do we ensure that activities that treat them differently do not make them feel like there are being judged or assessed, or make them feel they need to perform to meet adult expectation or approval.

Oral abstracts

Engaging Family

There were several presentations on engaging with families. It is interesting to see the work that is being done with families who help them to better understand and support their trans children. One reflection that I had, was on how can support services better recognise a diversity of support needs amongst parents.

From my own experience I wonder about the targeting. In my experience the parents and carers who show up, who are reachable with interventions, are less likely to benefit from basic trans 101 education and support with things like ‘ambiguous loss’. As a trans person and a parent in such spaces, I have found some ‘support’ to be really upsetting, and I know plenty of cis parents who have felt the same – who have needed support in managing state oppression and the minority stress of being a family facing overt anti trans abuse and hate, who have found sessions focused on ambiguous loss or trans 101 a world away from the support that they actually need.

On the topic of ambiguous loss I also wonder how we can better recognise the way in which rhetorics of ambiguous loss provide some parents with a cushion that enables them to gain emotional support from trans-ignorant cis communities – for that parent, moving away from a rhetoric of ambiguous loss also means moving away from their available emotional support network. That support network needs to be replaced by a trans-positive support network, and I’d really be interested in seeing how support for parents can focus less on trans 101 or on dealing with ambiguous loss, and more on building trans positive emotional support networks, reducing the isolation of supportive parents/carers, and on providing meaningful support to help families facing state persecution, helping parent/carers emotionally stay afloat whilst engaging in constant advocacy for child rights and whilst facing harassment, isolation and abuse.

Especially in context where oppression is high and rising, I would love to see more focus on how to ensure supportive parents and carers can not fall apart under the strain. Of course, the trans-hostile and trans ignorant parents are also very important – I would just not assume that they are the parents who will voluntarily walk through the door. Unless you have other means of reaching such parents (eg direct referral from the GP, or targeted outreach with a less supportive parent building on a connection with a more supportive parent), I wouldn’t assume you are ever meeting those parents.     

I would also like to see more consideration within those facilitating and organising parent/carer support groups of how to ensure the spaces do not expose parents/carers to an excessive amount of anti-trans opinion. In my experience those spaces work best when they are a good mix of parents who have become strongly supportive and educated, who are actively fighting for trans children’s rights and those parents who are new and managing their own learning curve. I have noted a tendency for the facilitation of these spaces to have shifted towards younger, non-parent and trans facilitators. I have also noted a growth in space for parents to discuss at length their own transphobic assumptions, where facilitators perhaps want every parent to have their say and don’t feel able to police any minimum standards of respect. The last ‘support’ group I attended I was directly called a ‘traitor to feminism’ for being a non-binary person in a facilitated group discussion without any backup.

(as well as being a toxic work environment for a younger trans facilitator) this ‘let everyone speak their mind’ approach is also driving away those parents who are more supportive. The cis parents who are attending in search of a safe space away from a trans-hostile world are encountering yet more trans hostility in those facilitated support spaces, and many are stopping attending. I myself more often than not find such spaces traumatising rather than reinvigorating, and I know many cis parents who feel the same. If the more supportive parents, who are looking for support on trans advocacy and dealing with transphobia get deterred from support groups, then that is a huge loss to those new parents who usually learn a lot of trans positivity and how to better support their children from parents who have walked the same path. I would be interested to hear more research that recognises the diversity of positionality within parents groups (including the existence of trans parents in those spaces), how to ensure those spaces are overall safe spaces for all parents (whilst providing some space for parents sharing their worries), and a mechanisms for more targeted approaches where a trans 101 isn’t the starting point for all families, with an emphasis on the support required beyond trans 101.

I always find the topic of ‘ambiguous loss’ a bit triggering. Clearly some parents do experience it, and need some therapeutic support with it. I wish there was more recognition of the diversity of ambiguous loss. In my experience a majority of parents experience ambiguous loss, which when you dig deeper is about a loss of safety. Especially for white families in countries and areas not particularly affected by violence or conflict, parents have an expectation of safety for their child. When they realise their child is trans, parents can have a reaction of fear, that their child is not going to be safe, in the present or in the future. This loss of expected safety is something that parents can find emotionally upsetting. In a world where there isn’t much language, parents can fall to a language of ‘grief’ to explain this loss. For some parents who I know, the language of grief is a mis-application, describing something that is different to grief. I’d like to see more focus on loss of safety as a concept, including helping parents to re-examine and re-conceptualise what they are feeling, especially where their feelings are not really about grief.

Clearly some parents also feel something like grief. One presenter mentioned an initiative on creative writing to help parents process their emotions. They included a description of a parent writing a eulogy. I am not a counsellor and don’t know how best to help parents who feel that way. I do worry about how much acceptance or space we should give for a grief narrative in more general or plenary spaces. It is clearly offensive. I also worry about the impact of giving space to a grief narrative on those parents and carers who have actually lost a child. Parent support spaces should be a safe space for those parents too, and I think more care should be taken over how ‘ambiguous loss’ is dealt with, including ensuring there are spaces for parents who want to talk about a loss of safety without having to hear other parents talk about ‘grief’ for a still alive child.

Law, Policy and Ethics

This included a presentation on the reasons why a proposed NHS research trial on puberty blockers is unethical, as well as evidence on the negative impacts of US healthcare bans.

Community engagement

This was a fantastic session, centring trans led research including from India, centring trans-led community designed research, the roles of community initiatives in steering research or clinical practice, and the importance of gaining service user trust.

Other conversations

I had many other interesting conversations. In many countries it was shocking to me to hear just how very far ahead of the UK in terms of treatment and support for trans children and adolescents they are. Folks from many countries expressed concern and solidarity on just how bad the UK is right now, seeing it as so very far behind acceptable levels of care, law and policy. I heard about interesting upcoming work, about current practice in the US, Canada, Australia, New Zealand, about support for trans youth in countries like South Africa and Vietnam, about upcoming research on disassociation, about initiatives to support folks under state violence. I met many awesome people who I hope to stay in touch with.

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