Submission to WPATH on the draft SOC8 intersex chapter

On 2 December, WPATH issued a call for public comment on draft chapters for the Standards of Care for the treatment of transgender and gender diverse people, seeking feedback by 16 December. It includes a chapter on intersex. The request for comment, which was forwarded to us, notes that the draft has

“been approved by every member (120+) of the SOC8 (approval required 75% acceptance rate). While statements likely cannot be changed, there is more opportunity to make edits to the explications of the statements.”

This is an uncomfortable situation. There is nothing intrinsic to being a professional organisation for transgender health that means that members have any expertise on intersex health and wellbeing and, in fact, we have significant evidence of misrepresentation of intersex health issues as if they are transgender health issues within such spaces. The draft Standards include a draft chapter on intersex that gives us profound cause for concern. Given our concerns, we also reviewed draft chapters on “child”, ethics and surgery.

Surprisingly, the draft chapters are marked “confidential draft for public comment” and “not for distribution”. How is a public consultation process supposed to proceed on this basis? These contradictions illustrate the violence of this hasty, inadequate consultation process. Our review has found that, in supporting medical interventions on children with intersex variations that are grounded in psychosocial rationales and gender stereotypes, WPATH proposes to facilitate human rights abuses, and this is incompatible with chapters on ethics, children and surgery.

Our responses to the consultation survey on the intersex chapter were written by Morgan Carpenter, executive director, with contributions and feedback from Cody Smith and the board of IHRA. It also benefits from broader international community debate, though this was limited by unnecessary constraints imposed on the consultation process by WPATH. Our responses are as follows. Please note that, unless otherwise specified, all quotations are from the WPATH draft intersex chapter.

UPDATE 17 DECEMBER: At 3.32am AEDT on 17 December we received an email notifying us of a one month extension to the consultation period.

Comments on the introduction of the draft intersex chapter

The nomenclature used in this chapter is idiosyncratic, evident in some works by Meyer-Bahlburg (e.g. 2019), but not otherwise used in English-speaking contexts. “Physical intersexuality” presumes the existence or validity of other forms of intersex, which should not be taken as granted, particularly when the use of the term intersex as a gender identity label is at odds with all available evidence suggesting that most people with intersex variations have female or male identities (including both cisgender and transgender women and men with intersex variations), and at odds with respect for that diversity.

Standard definitions of the word intersex (promulgated by the UN Office of the High Commissioner for Human Rights (2019) and other institutions) use the term to refer only to physical characteristics. An intent of the use of the term “physical intersexuality” while also referring to “DSDs” appears to be an attempt to narrow the meaning of the term intersex, and maintain the relevance of widely opposed and non-neutral language of “disorders of sex development”. Indeed, in a context where current medical practices (such as early genital surgeries) are highly contested and the subject of attention by human rights institutions, disputes around nomenclature appear to have the intent of maintaining current medical practices as far as possible. The nomenclature has the effect of narrowing the scope of the chapter.

Lacking a foundational relationship with the intersex human rights and peer and family support movements, and lacking broad expertise on intersex health (as indicated in statement 2), WPATH does not have the standing to propose novel terminology, nor make recommendations beyond those affecting the health of gender diverse people.

The introduction acknowledges that most:

“physical variations among individuals with intersexuality [sic] neither impair function, at least in the early years, nor risk safety for the individual. Yet, the psychosocial stigma associated with atypical genital appearance often motivates early ‘normalizing’ genital surgery long before the patient reaches the age of consent. This approach is highly controversial, because it conflicts with ethical principles supporting patient autonomy”

This is a “reporting of a controversy” while purporting to not take a position. A position in support of early surgeries is, however, evident in Statement 9. This “controversy” exists because psychosocial rationales for early surgery are associated with gender stereotypes about physical appearance and function, and they are known to be poorly evidenced (Lee et al 2016), yet they are treated as self-evident justifications for surgeries.

WPATH must take a firm position recognising the human rights of people with intersex variations. Only such a position is compatible with the chapter on “ethics”. WPATH must recognise the importance of psychosocial support – and not prepubertal surgical and hormonal interventions – to “minimize adversities” and mitigate distress without surgical interventions. Only such a position is compatible with the chapter on “child”.

References

Lee, Peter A., Anna Nordenström, Christopher P. Houk, S. Faisal Ahmed, Richard Auchus, Arlene Baratz, Katharine Baratz Dalke, et al. 2016. ‘Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care’. Hormone Research in Paediatrics 85 (3): 158–80. doi:10.1159/000442975.

Meyer-Bahlburg, Heino F. L. 2019. “Dogma-driven legal regulations versus evidence based clinical guidelines in intersex management”. Journal of the American Academy of Child & Adolescent Psychiatry, 28(10S), s. 279-280.

Office of the High Commissioner for Human Rights. 2019. ‘Background Note on Human Rights Violations against Intersex People’. https://www.ohchr.org/EN/Issues/Discrimination/Pages/BackgroundViolationsIntersexPeople.aspx.

Yogyakarta Principles. 2017. The Yogyakarta Principles Plus 10: Additional Principles and State Obligations on the Application of International Human Rights Law in Relation to Sexual Orientation, Gender Identity, Gender Expression and Sex Characteristics, to Complement the Yogyakarta Principles. http://www.yogyakartaprinciples.org/principles-en/yp10/.

Statement 1: We suggest that a multidisciplinary team, knowledgeable in diversity of gender identity and expression as well as in physical intersexuality, provide care to patients with physical intersexuality and their families.

This statement is an appeal for jurisdiction over the treatment of cisgender and gender conforming children with intersex variations. This is offensive while, at the same time, statement 9 facilitates human rights abuses such as “gender-confirming” surgeries on those children.

The existence of multidisciplinary teams does not, in and of itself, mean that the human rights of infants, children and adolescents with intersex variations is respected (Consortium on the Management of Disorders of Sex Development 2006, 1) and such teams have been used to circumvent external scrutiny, transparency and oversight (Vora et al 2016; Thomsett and Warne 2021), and to justify treatment that violates the rights of the child (Intersex Human Rights Australia 2018, 50-52). This statement instead suggests a commitment to a status quo that sees routine violations of the human rights of children with intersex variations.

The unnecessary reference to “her/his family” is incompatible with the “nonbinary” chapter and respect for the diversity of the population.

References

Consortium on the Management of Disorders of Sex Development, California Endowment, Arcus Foundation, and Tides Foundation. 2006. Clinical Guidelines for the Management of Disorders of Sex Development in Childhood. Whitehouse Station, N.J.: Accord Alliance, c2008.

Intersex Human Rights Australia. 2018. ‘Submission to the Australian Human Rights Commission: Protecting the Human Rights of People Born with Variations in Sex Characteristics’. https://ihra.org.au/32490/ahrc-submission-2018/.

Thomsett, Mike, and Garry Warne. 2021. ‘History’. Australasian Paediatric Endocrine Group. April. https://apeg.org.au/about-apeg/history/.

Vora, Komal A, Chloe Hanna, Philip Bergman, Justin Brown, Rebecca Deans, Sonia Grover, Yves Heloury, et al. 2016. ‘Multidisciplinary Team (MDT) Review of Management Decisions in Disorders/Differences of Sex Development (DSD): Experience of Two Paediatric Tertiary Hospital Networks’. Presented at the Australasian Paediatric Endocrine Group Annual Scientific Meeting – APEG 2016, Alice Springs, NT: Alice Springs Convention Centre, August 14.

Statement 2: We recommend that health professionals providing care for transgender youth and adults seek training and education in the aspects of intersex care relevant to their professional discipline.

Improved comprehension and proficiency of all medical and health professions on intersex-related healthcare is desirable. However, it is our view that proficiency in intersex healthcare is incompatible with disregard for the human rights of people with intersex variations.

This statement fails to address ongoing human rights abuses which remain perpetrated in clinical settings by multidisciplinary teams. The statement presumes the effectiveness of multidisciplinary teams in the past and accordingly it implicitly endorses such abuses and facilitates them.

Statement 2 is a prerequisite for later statements, as those later statements assume proficiency in intersex health. This is not clearly established.

Statement 3: We suggest that health professionals educate and counsel families of children with physical intersexuality from the time of diagnosis onward about their child’s specific intersex condition and its psychosocial implications.

While the draft SOC8 chapter on children identifies psychological support as appropriate to overcome shame, distress and social stress, statement 9 in this chapter supports early surgical interventions. Such statements are incompatible with respect for the human rights of children with intersex variations.

We support the recommendation that health care providers adopt affirmative language and attitudes, and normalise the existence of intersex people, not only across education and counselling functions, but in all interactions with intersex patients and their families. The use of denigrating and pathologising language in a clinical setting has been identified as a significant source of stigma and shame (Johnson et al 2017). The use of the idiosyncratic language in this chapter does not promote affirmative support.

A lack of non-surgical treatment pathways has been identified in research on current clinical practices (Liao et al 2015; Roen 2019). Without any mention of alternative treatment pathways, or the right to refuse intervention, this material seems to seek to ameliorate coercion (“if a patient has enough information to agree with us, it counts as consent”).

While the statement notes that intersex people have been included in some multidisciplinary teams, the statement fails to endorse this practice. The statement should instead require that at least one community-connected intersex person should be included on every multidisciplinary team. In addition, the statement should require the provision of information about intersex-led support groups and contact details for relevant local support groups who are able to provide individualised support.

This statement is pre-emptive, depending on statement 2 as a prerequisite, as health professionals working with transgender youth and adults lack competence or expertise on the treatment of people with intersex variations. This statement seems likely to increase the frequency of unhelpful conflations of the needs and circumstances of intersex and transgender populations. Indeed, we have documented many examples of experts on transgender treatment misrepresenting intersex people and health concerns as matters associated with a third sex category that is explicitly rejected in our regional intersex community declaration (AIS Support Group Australia et al 2017). Current examples include Royal College of Pathologists of Australasia (2020) and Hosking (2021).

We advise a more cautious approach, acknowledging an historical lack of attention to the specific health and wellbeing needs of intersex populations, and acknowledging that entering this space, and addressing the specific needs of the population, requires humility and a willingness to turn to those with lived experience for guidance.

References

AIS Support Group Australia, Intersex Trust Aotearoa New Zealand, Organisation Intersex International Australia, Eve Black, Kylie Bond, Tony Briffa, Morgan Carpenter, et al. 2017. ‘Darlington Statement’. https://darlington.org.au/statement.

Hosking, Glen. 2021. ‘What Are Gender Pronouns and Why Is It Important to Use the Right Ones?’ The Conversation, October 15. http://theconversation.com/what-are-gender-pronouns-and-why-is-it-important-to-use-the-right-ones-169025.

Johnson, Emilie K., Ilina Rosoklija, Courtney Finlayson, Diane Chen, Elizabeth B. Yerkes, Mary Beth Madonna, Jane L. Holl, Arlene B. Baratz, Georgiann Davis, and Earl Y. Cheng. 2017. ‘Attitudes towards “Disorders of Sex Development” Nomenclature among Affected Individuals’. Journal of Pediatric Urology, May. doi:10.1016/j.jpurol.2017.03.035.

Liao, Lih-Mei, Dan Wood, and Sarah M Creighton. 2015. ‘Parental Choice on Normalising Cosmetic Genital Surgery’. BMJ 351 (September): h5124. doi:10.1136/bmj.h5124.

Roen, Katrina. 2019. ‘Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice’. The Journal of Sex Research 56 (4–5): 511–28. doi:10.1080/00224499.2019.1578331.

Royal College of Pathologists of Australasia. 2020. ‘Pathology Testing for Transgender and Intersex Individuals – Statement of Best Practice for Medical Pathology Laboratories’. https://www.rcpa.edu.au/Library/College-Policies/Position-Statements/Pathology-Testing-for-Transgender-and-Intersex-Ind.

Statement 4: We suggest that both providers and parents engage children/individuals with physical intersexuality in ongoing, developmentally appropriate communications about their intersex condition and its psychosocial implications.

This statement is incompatible with statement 9 which supports early surgical so-called “normalizing” interventions.

In line with the endorsement of positive communication, this recommendation should be extended to recommend that individuals and parents be given an opportunity to communicate with intersex people, i.e. people with lived experience.

Statement 5: We suggest that health professionals and parents support children/individuals with physical intersexuality in exploring their gender identity throughout their life.

The material supporting this statement suggests that individuals experiencing “gender incongruence” consider “gender-affirming interventions”. These individuals may, however, include the 5-10% of individuals with CAH who are “non-cisgender”, and who may have experienced the “gender-confirming interventions” supported by statement 9. This highlights the flaw in accepting at face value any survey suggesting that a majority opinion should dictate the exposure of any infant or child to surgical intervention.

Overall, this material appears to assume that the existence of particular physical characteristics causes or should cause a questioning of gender identity. These are surprising assertions for a transgender health organisation. Certainly the problematisation of intersex characteristics, including risks and experiences of surgical and hormonal interventions, examinations and testing, are likely to cause introspection about the reasons for that problematisation, and this may in turn raise questions about identity and belonging. To limit this to questions of gender identity might be regarded as reflecting an insularity commensurate with the interests and scope of WPATH. While everyone deserves an opportunity to make their own decisions in line with their values and preferences, including about their bodies and identities, repeated attention to these matters can be interpreted to be harassment or stigmatisation.

Recognition of gender variability for intersex people must lead to a strong recommendation against deferrable interventions aimed at erasing “ambiguity” and uncertainty. It is of dubious value to suggest that healthcare practitioners offer counselling to support children and their parents in exploring gender if healthcare practitioners have intervened to make intersex bodies fit stereotypical understandings of male and female appearance and function.

Statement 6: We suggest that health professionals promote well-being and minimize the potential stigma of having an intersex condition by working collaboratively with both medical and non-medical individuals/organizations.

This statement, and supporting references to the Yogyakarta Principles, are incompatible with support for “early ‘normalizing’ genital surgery” due to “psychosocial stigma associated with atypical genital appearance”. As the material supporting this statement points out, medical interventions are frequently predicated on a fear of stigmatisation, while genital examinations consequential to surgeries and secrecy cause risks to self-esteem and empowerment. Community connection, access to peers, openness and acceptance are all protective factors for mental health and wellbeing, but WPATH has chosen not to recognise the role that these should play, instead of early surgical intervention.

It seems unlikely to us that there is benefit in transgender health organisations educating the public about the existence of intersex people and traits. It seems to us more likely that such an undertaking will reify associations between intersex bodies and ideas about gender dysphoria and gender transition. This kind of association is partly responsible for popular misconceptions that intersex variations are a gender identity. Leadership on these matters is for the “active movement within the intersex community to alleviate stigma and return human rights and dignity to intersex people”.

Statement 7: We suggest that health professionals refer patients with physical intersexuality and their families to mental-health providers as well as peer and other psychosocial supports as indicated.

We support routine referral to mental health providers and intersex-led peer and family support organisations that are experienced in the provision of care to people with intersex variations and our families.

Statement 8: We recommend that health professionals counsel patients with physical intersexuality and their families about puberty suppression and/or hormone treatment options within the context of the patient’s gender identity, age and unique medical circumstances.

The statement that a majority of people with intersex variations “have a gender identity in line with their XX or XY karyotype” is unsupported by a citation. This might be attributed to the size of the XX CAH population, but it is a dubious generalisation that is a disservice to other populations, such as women with androgen insensitivity or XY gonadal dysgenesis. It is also a disservice to people with sex chromosome variations who play an active role in intersex-led organisations, including those offering peer and family support. It is surprising to see a transgender health organisation link chromosomes to gender identity.

In general, the focus of this material, like the focus of other statements, is on producing treatment, including through problematising the bodies of intersex people until a course of treatment is produced. WPATH should attend to the benefits of watchful waiting.

“Gender assignment” is not synonymous with “gender-confirming” interventions. Since the mid-1990s, intersex advocates have called for best-fit (binary) sex/gender assignment without surgical or hormonal treatment unless necessary for physical health, until individuals are able to freely express their own values and preferences (Dreger 2018; AIS Support Group Australia et al 2017). Further, clinical thinking is still predicated on ideas that “surgical options” are a valid consideration where “Sex assignment is a dilemma”, and that sex of rearing significantly predicts future adult gender identity (Vora and Srinivasan 2020, 418).

References

Dreger, Alice. 2018. ‘Twenty Years of Working toward Intersex Rights’. In Bioethics in Action, 55–73. Cambridge University Press. doi:10.1017/9781316343197.004.

Vora, Komal A, and Shubha Srinivasan. 2020. ‘A Guide to Differences/Disorders of Sex Development/Intersex in Children and Adolescents’. Australian Journal of General Practice 49 (7): 417–22. doi:10.31128/AJGP-03-20-5266.

Statement 9: We suggest that health professionals counsel parents and patients with physical intersexuality (if cognitively sufficiently developed) to delay gender-confirming genital surgery, gonadal surgery, or both, when feasible, so as to optimize the child’s self-determination and ability to participate in the decision based on informed consent.

This statement and material comprises a psychosocial justification of unnecessary, and often unwanted, irreversible and invasive medical interventions. The statement implies that the only question is one of timing. This statement is incompatible with other draft chapters in SOC8, including the chapters on “ethics” and “child”. The mere “suggestion” in the statement of a delay to “gender-confirming genital surgery, gonadal surgery, or both” is entirely inadequate. WPATH must instead affirm the human rights of people with intersex variations, including the right to remain free of any or all medical or surgical interventions.

The “ethics” chapter recognises the human rights of transgender and gender diverse people, including the importance of the Yogyakarta Principles and Yogyakarta Principles plus 10. These are universal principles that also apply to intersex people. Principle 32 on the Right to Physical and Mental Integrity states: “No one shall be subjected to invasive or irreversible medical procedures that modify sex characteristics without their free, prior and informed consent, unless necessary to avoid serious, urgent and irreparable harm to the concerned person.” The SOC8 must be consistent across chapters and recognise that the same rights apply to people with intersex variations.

The “child” chapter identifies consideration of psychotherapy as an appropriate response to stress, distress and shame, in order to improve psychosocial health. That chapter identifies lack of social acceptance as “not because of some shortcoming in the child” but because of lack of understanding in the “social environment”. This chapter should be consistent with the chapter on children, recognising that intersex children should not be forced or otherwise pressured to conform to social norms. The provision of psychosocial support aimed at facilitating self-determination should be routinised.

The ”surgery” chapter sets out in detail in statement 4 the appropriate conditions and evidence for consideration of “gender affirming” surgeries. This chapter uses an idiosyncratic term, “gender-confirming genital surgery” and fails to disclose the appropriate conditions and evidence for consideration of such interventions. This likely reflects a lack of so-called “consensual attitude” amongst healthcare practitioners for surgery timing, indications, and evaluation of outcome (Lee et al 2016), and these factors should mean that WPATH takes a position that, instead, respects the human rights of the child, including the right to refuse any or all so-called “normalising” surgical interventions.

It is inappropriate for the supporting text to cite an unpublished chapter in support of an assertion that “ten published surveys of clinic patients” show support for early surgeries. In addition to this unscientific way of presenting an assertion that cannot be fully examined or tested, this statement suggests that evidence is being constructed in order to achieve a predetermined outcome. This is a form of bias.

The material supporting this statement cited Bennecke et al (2021). This study notes the risk of selection bias. The authors state: “as participants were partly contacted through medical personnel, a fact that might have suggested compliance with medical authority in these debates. Also, the title of the study ‘dsd-LIFE’ may have deterred those who object to the term ‘disorders of sex development.’ In DSD, loss to follow-up is frequent” (Bennecke et al 2021). Indeed, a 2016 global clinical statement comments that “The practice of withholding medical history details, along with the possibility of negative medical experiences, likely contributes to patients with DSDs frequently being ‘lost to follow-up’” (Lee et al, 2016).

This study reported by Bennecke et al. emerged out of the European “dsd-LIFE” project. A researcher involved in establishing this project, French paediatric endocrinologist Claire Bouvattier, has been highly critical of its results. Before a hearing of the Court of Cassation on bioethics and law in January 2019, she advised that 5000 participants were expected to participate, but only 1000 were recruited (Cour de Cassation 2019, 35:00-36:06), with only 400 of them having atypical genital characteristics:

“When we look at the studies that were conducted on its 1000 patients, you see that almost all were operated on before they reached 4 years old […] and we still saw, while listening to the patients, when you question these women who have congenital adrenal hyperplasia, there is a big negative impact on the quality of life from clitoral surgery… (Original text in French: “[q]uand on regarde les études qui ont été faites sur ses 1000 patients, vous voyez que quasiment tous ont été opérés avant 4 ans […] et on a quand même en entendant ses patients vu que, quand vous interrogez ses femmes qui ont une hyperplasie congénitale des surrénales, il y a gros impact négatif sur la qualité de vie de la chirurgie du clitoris…” (Cour de Cassation 2019, 36:06-36:28).)

Of this non-random sample, a minority of the respondents with CAH supported surgery before age 3, with another small group supporting surgery between ages 4 and 12. It is not appropriate to extrapolate from this data that early surgeries for genital appearance or so-called “normalisation” are acceptable. It is not clear what level of disagreement amongst study respondents might justify to WPATH deferring surgeries that are not necessary for physical health. When early surgeries are permitted, they risk exposing all the 5-10% of individuals with CAH reported to have “non-cisgender identities” to unwanted irreversible surgeries. The abandonment of this population through such a policy is a shocking abrogation of responsibility by a transgender health organisation.

Some individuals accept early surgical interventions. This is true not only of early so-called “normalizing” interventions, but also female genital mutilation and, indeed, all situations where individual preferences are distorted by stigma, discrimination, and harm. Martha Nussbaum describes these as “adaptive preferences”, a well-understood phenomenon and an unreliable guide to individuals’ entitlements or rights.

Nussbaum rejects “utilitarian preference-based approaches as a basis for fundamental political principles precisely because they were unable to conduct a critical scrutiny of preference and desire that would reveal the many ways in which habit, fear, low expectations, and unjust background conditions deform people’s choices and even their wishes for their own lives” (Nussbaum 2000, 114). Nussbaum rejects “subjective welfarism” where “all existing preferences are on a par for political purposes, and that social choice should be based on some sort of aggregation of all of them” (Nussbaum 2000, 116-7). Nussbaum comments that “subjective welfarism makes it impossible to conduct a radical critique of unjust institutions” (Nussbaum 2000, 117). Such unjust institutions include those where stigma, parental distress and gender stereotypes are accepted as rationales for early appearance-altering genital surgeries. Children are still entitled to respect for their fundamental human rights, as described in the “ethics” chapter.

There is no ethical reason to conduct a study on personal acceptance of practices that violate their human rights (Carpenter 2021).

References

Carpenter, Morgan. 2021. ‘Keynote Presentation’. Presented at the Intersex 2021 – A Vision for the Future, Dublin City University, April 21. https://morgancarpenter.com/keynote-intersex-2021/.

Cour de Cassation. 2019. Cycle droit et bioéthique – Identité, sexe et genre. YouTube. https://www.youtube.com/watch?v=1OhMZAPolbE

Nussbaum, Martha C., ed. 2000. ‘Adaptive Preferences and Women’s Options’. In Women and Human Development: The Capabilities Approach, 111–66. The Seeley Lectures. Cambridge: Cambridge University Press. 10.1017/CBO9780511841286.004.

Statement 10: We suggest that only surgeons experienced in intersex genital or gonadal surgery operate on patients with physical intersexuality.

The argument that only surgeons experienced in treatment of intersex people should perform surgeries on the sex characteristics of intersex people is superficially a rational argument. However, it is associated with claims that surgeon inexperience is responsible for poor surgical outcomes for intersex people, which then props up assertions that human rights concerns can be addressed by adequately improving surgical techniques and outcomes. (Hutson 2020; Carpenter 2021). It is a dubious argument that distracts from more substantive and pressing concerns around the necessity of surgery. All patients – intersex and endosex – need access to the best available surgery by the best available surgeons, at a time when they are able to provide personal informed consent or, failing that, in an emergency situation.

References

Carpenter, Morgan. 2021. ‘Keynote Presentation’. Presented at the Intersex 2021 – A Vision for the Future, Dublin City University, April 21. https://morgancarpenter.com/keynote-intersex-2021/.

Hutson, John. 2020. ‘Short, Medium and Long-Term Outcomes for DSD at The Royal Children’s Hospital’. In Disorders|Differences of Sex Development: An Integrated Approach to Management, edited by John Hutson, Sonia R. Grover, Michele A. O’Connell, Aurore Bouty, and Chloe A. Hanna, 305–18. Singapore: Springer. doi:10.1007/978-981-13-7864-5_23.

Statement 11: We recommend that health professionals who are prescribing or referring patients for hormonal therapies/surgeries counsel individuals with physical intersexuality and fertility potential and their families about a) known effects of hormonal therapies/surgery on future fertility; b) potential effects of therapies that are not well studied and are of unknown reversibility; c) fertility preservation options; and d) psychosocial implications of infertility.

This statement needs to treat statement 2 as a prerequisite. Transgender health professionals typically have inadequate understanding of intersex traits and are not able to provide advice on fertility. Additionally, statement 9 proposes that perceived future risk of stigmatisation and other psychosocial rationales can justify unnecessary so-called “normalizing” surgeries that may eliminate potential fertility, and clinicians who adhere to such rationales have no business in providing advice on fertility.

Healthcare professionals should be open to various modes of fertility, including fertility options which are not traditionally associated with the sex/gender of the intersex person. For individuals raised female, the possibilities of fertility using male gonadal material, or female gonadal material for those raised male should be carefully considered before any sterilising medical interventions are undertaken.

Clinicians performed medical interventions appear to have traditionally been more concerned with fertility options for individuals raised female than those raised male. Clinicians should carefully consider fertility options irrespective of sex of rearing.

People experiencing infertility must be empowered to stay in touch with changes and emerging new parenthood options throughout life.

Statement 12: We suggest that health professionals caring for patients with physical intersexuality and congenital infertility introduce them and their families, early and gradually, to the various alternative options of parenthood.

This statement needs to treat statement 2 as a prerequisite. Transgender health professionals typically have inadequate understanding of intersex traits and are not able to provide advice on fertility. Additionally, statement 9 proposes that perceived future risk of stigmatisation and other psychosocial rationales can justify unnecessary so-called “normalizing” surgeries that may eliminate potential fertility. Clinicians who adhere to such rationales that favour sterilisation without clear and substantiated, pressing evidence of cancer risks have no business in providing advice on fertility.

Healthcare professionals should be open to various modes of fertility, including fertility options which are not traditionally associated with the sex/gender of the intersex person. For individuals assigned female, the possibilities of fertility using male gonadal material, or female gonadal material for those assigned male should be carefully considered before any sterilising medical interventions are undertaken.

Clinicians who have performed medical interventions appear to have traditionally been more concerned with fertility options for individuals assigned female than those assigned male. Clinicians should carefully consider fertility options irrespective of sex.

People experiencing infertility must be empowered to stay in touch with changes and emerging new parenthood options throughout life.

Comments on the Overall Chapter

Overall, this chapter facilitates human rights abuses that should be rejected and seeks to expand the role of WPATH without justification. This chapter is incompatible with other chapters. In particular:

The “ethics” chapter recognises human rights norms and principles such as the Yogyakarta Principles plus 10 in ways that are disregarded in this chapter.
The “child” chapter recognises that psychosocial concerns can and should be addressed by psychological support, and makes no mention of surgical interventions in order to address psychosocial risks. This chapter inappropriately treats surgical interventions on children as a valid response to psychosocial concerns.
The “surgery” chapter presents in detail the conditions under which “gender affirming” surgeries may take place, but this chapter fails to present the conditions under which euphemistically-named “gender-confirming genital surgeries” might take place.

The chapter relies on an unpublished paper by the committee chair to underpin key arguments. We are unable to test or examine claims made in that paper, and this process is suggestive of an attempt to manufacture a predetermined outcome. This is completely unacceptable and unscientific.

Neither WPATH nor local ANZPATH or AUSPATH organisations have played any active role in contributing to discussion about clinical practices affecting intersex people in Australia, with no contribution to major inquiries by our Senate (2013) or the Australian Human Rights Commission (2021). Indeed, we wrote to ANZPATH in 2014, following the Senate inquiry, asking that organisation to remove intersex from its then purported remit (OII Australia 2014). Lacking a foundational relationship with the intersex human rights and peer and family support movements (mentioned in the material supporting statement 6), and lacking broad expertise on intersex health (as indicated in statement 2), WPATH and its local equivalents do not have the standing to propose novel terminology, nor make recommendations on the health and wellbeing of people with intersex variations, beyond those affecting the health of gender diverse people.

We are led to understand that the draft chapter has been approved by members of an organisation that has no evidenced expertise on intersex health and wellbeing. Surprisingly, the draft chapter is marked “confidential draft for public comment” and “not for distribution”. How is a public consultation process supposed to proceed on this basis? These contradictions are indicative of a consultation process that is hasty, inadequate and violent. If the chapter cannot be rewritten to ensure respect for the human rights of people with intersex variations in medical settings, the most prudent way forward would be to discard the chapter entirely.

References

Australian Human Rights Commission. 2021. Ensuring Health and Bodily Integrity: Towards a Human Rights Approach for People Born with Variations in Sex Characteristics. Sydney, Australia: Australian Human Rights Commission. https://humanrights.gov.au/intersex-report-2021.

OII Australia. 2014. Intersex and ANZPATH. https://ihra.org.au/27702/intersex-and-anzpath/.

Senate of Australia Community Affairs References Committee. 2013. Involuntary or Coerced Sterilisation of Intersex People in Australia. http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Involuntary_Sterilisation/Sec_Report/index.