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Ruth Pearce @NotRightRuth
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We're now moving into the closing plenary of #wpath2018. There will be a closing ceremony this afternoon, but first we're hearing an update on the draft Version 8 WPATH Standards of Care.
We're hearing from Standards of Care committee chair Eli Coleman. "This is a much more robust process than we've ever achieved before".

Process informed by published scientific/research evidence, patient factors/clinical circumstances, and clinical expertise. #wpath2018
Process for writing WPATH SOC 8:
- identify scope
- convene committees for specific topics
- refine questions
- assess evidence
- draft guideline
- external peer review
- disseminate guidelines
Coleman: WPATH members invited to apply to be chapter leads and chapter committee members, asked to submit CV. Appointed on basis of ability to review evidence-based literature. Combination of scholars/researchers, clinicians, and representatives of community groups. #wpath2018
Coleman: Chapter committee members from all over the world.

(but: mostly from North America and Europe) #wpath2018
New developments for SOC 8:

- separating chapters for children and for adolescents
- chapter for non-binary individuals
- chapter on sexual health across the lifespan
- chapter on applicability to eunuchs
- new chapter(s) on competency, training, education ethics
Sam Winter is now speaking on the chapter on the "Global Applicability of the Standards of Care". Will look at context of trans healthcare and provision of services worldwide, and list core principles. #wpath2018
Sari Reisner on "Terminology - Diagnostic Criteria".

Reisner jokes: "This will be a very simple chapter. Absolutely no controversy".
Reisner: What is considered affirming and current varies greatly according to culture, context and history. Important to be clear on this and acknowledge that best practice will change. Important not to have US/Euro-centric way of introducing terms. #wpath2018
Reisner: Group has reviewed language in SOC 7 and other terminology documents, and other guides to trans language use in different contexts. Considering how to de-gender language, acknowledge tensions in defining language. #wpath2018
Next up in this rapid-fire session: Michael Goodman on Chapter III: Epidemiologic considerations.

Trying to understand the size and distribution of the population (in terms of time, place, population characteristics). Reviewed 43 articles to date, 1968-2018. #wpath2018
Committee member Katie Spencer speaking on Chapter IV: Overview of Therapeutic Approaches for Gender Health (as chair Mick van Trotsenburg can't be here).

Spencer's slide: important that therapeutic approaches are optional. #wpath2018
Madeline Deutsch speaking on Chapter V: The role of primary care in general health. Deutsch acknowledges that it's mostly a US authorship - "not many qualified applicants from anywhere else - this something something we're recognising and trying to address". #wpath2018
Deutsch lists subject areas for primary care chapter, which include (non-exhaustive list): lipids, cardiovascular issues, bone-related issues, cancer prevention, approach to age, sexual health support, informed consent approach to hormone therapy, homeless support. #wpath2018
Deutsch on example recommendations for SOC 8 primary care chapter:
- hormone therapy is within the scope of practice for primary care
- withholding hormone therapy to prevent cardiovascular disease is not supported by evidence
Amy Tishelman on Chapter VI: Assessment, Support and Therapeutic Approaches for Children.

Issues include limited (but growing) evidence base primarily from Western world. There are different perspectives, but committee members are focusing on points of agreement. #wpath2018
Tishelman: There may not always be a role for health professionals, and may not be a role for psychological professionals in support for gender nonconforming children. Ultimately, kids are kids. #wpath2018
Tishelman: Recommendations include well-being assessment to inform guidance and problem-solving, as appropriate (or not) to each child and family. Not every trans or gender diverse child requires therapeutic support. #wpath2018
Scott Leibowtiz on Chapter VII: Assessment, Support and Therapeutic Approaches for Adolescents with Gender Diversity/Dysphoria. #wpath2018
Leibowitz on initial principles for adolescent chapter:
- acknowledgement of fuzzy boundary between adolescence and adulthood
- important that young people get timely treatment
- provider has role in reducing stigma in communities
- acknowledge spectrum of gender
Leibowitz: there are questions about age for adolescent intervention and the group are. Often it's a matter of individual development and experience.

Committee supports WPATH statement against conversion therapy.
Walter Bouman on Chapter VIII: Assessment, support and therapeutic approaches for non binary people.

Health professions should accept gender is on a continuum and may not conform to binary model. Non-binary people entitled to person-centred assessment and treatment. #wpath2018
Bouman: Access to medical transition should not be dependent on any particular gender identity or expression. Non-binary people may require additional support due to minority stress. Surgical interventions may be appropriate in absence of hormones or social transition. #wpath2018
Christina Richards on Chapter IX: Assessment of Adults with Gender Diversity or Dysphoria.

Set of guidelines that acknowledge autonomy of trans individuals while recognising various medical requirements and good practice in different parts of the world. #wpath2018
Dan Karasic on Chapter X: Managing mental and behavioural health conditions in adults.

Trying to be more precise about what it means to have a "mental health issue" that might interact with care. #wpath2018
Karasic: Mental health issues should be addressed so patient is able to give informed consent - but mental health diagnosis should not be a barrier to care. Often transition best undertaken at same time as treating mental health conditions. #wpath2018
Vin Tangpricha on Chapter XI: Hormone therapy for adolescents and adults. Bit more advanced progress than other chapters due to stronger evidence base. #wpath2018
Tangpricha on questions being raised about endrocrinology for expert review during writing. These include:
- comparative risks of oestrogens
- risk of polycythemia among trans men
- effect of testosterone on health of ovaries etc
- what do we do with progesterones?
Timo Nieder on Chapter XII: Sexual Health Across the Lifespan. 46 initial draft statements! Now narrowing these down and producing questions for evidence review team. #wpath2018
Nieder outlining some sample recommendations. e.g. STI screening for should be trauma informed. Possible approaches include self-collected rather than provider-collected swabs, but looking into evidence on this. #wpath2018
Juno Obedin-Malliver standing in for Leena Nahata on Chapter XVIII: Reproductive Health.

Thinking about big picture of reproductive health and capacity. Considering impact of hormone therapy, fertility preservation options, attitudes towards parenthood. #wpath2018
Obedin-Malliver: trying to look at whole spectrum of reproductive health to support trans people in not just surviving, but thriving and having families where this is a desire. #wpath2018
Obedin-Malliver on draft recommendations for reproductive health chapter, which include:
- information and counselling related to hormone therapy
- provdiers working with youth should receive training specifically on reproductive health
Adrienne Hancock on CHapter XIV: Voice and Communication.

Taking a person-centred approach. Acknowledging construction of gender, race etc through interpersonal interactions. #wpath2018
Hancock on voice and communication chapter:
- providers should focus on client's communication goals
- acknowledging limitations of person and provider in production of gender
- work with impact of hormones (what do we know and not know about what testosterone does?)
Hancock: Not sure if it makes sense to view communication goals in terms of either "transmasculine/transfeminine" or gender assigned at birth. More sense to focus on personal identity and social positioning in terms of gender/age/race. #wpath2018
Stan Monstrey on Chapter XV: Surgery chapter for adolescents and adults. #wpath2018
Major controversies for surgery chapter include:
- surgery in adolescents
- addition of facial procedures
- surgery on non-binary and gender diverse individuals
- assessments and what is required
- role of hormonal therapy surgery
- issues surrounding de-/re-transition #wpath2018
Chapter leads on Chapter XVI: Applicability of standards of care for people living in institutional environments. Trans prisoners face exceptional challenges. Vital that chapter provides support to lawyers seeking to ensure access to care. #wpath2018
Institutional care chapter will also be expanding scope from prisons to other institutional environments, such as nursing homes. #wpath2018
Chapter lead for Chapter XVII: Applicability of Standards of Care to people with intersex conditions absent. Authors deciding on chapter focus, looking at ethical issues and recommendations for care. Intersex activists in room looking hugely unimpressed. #wpath2018
Lead also absent for Chapter XVIII: Applicability of standards of care to eunuchs.
- misunderstanding of historical role of eunuchs can cause stress
- recognise eunuchs may not voluntarily disclose identity
- eunuchs may access interventions without medical support
Gail Knudson on Chapter XIX: Competency, training, education and ethics. Likely to split into 2 chapters. We've been asked not to publish draft recommendations. Broad focus here on gathering more evidence and information. Desire to incorporate non-Western perspectives. #wpath2018
Eli Coleman emphasises that Standards of Care 8 are very much work in progress. What exactly will they look like? No way to have a clear answer at this point. #wpath2018
Marci Bowers speaking from the floor. Stating that WPATH has an unfortunate reputation within trans communities. Standards of Care viewed as conservative, gatekeeping, slow, reactive not proactive. Urges Standards of Care committee to be bold. #wpath2018
Bowers: Reproductive rights are human rights. Removal of sterilisation requirement clauses is vital. So too is focus on patient consent rather than multiple assessments for surgeries that are not required of cis patients. #wpath2018
Bowers recieves a standing ovation from many of the intersex and trans people in the room. #wpath2018
Question from the floor: What is the Standards of Care committee doing to prioritise input from Global South, rather than just say "not many people applied?" This does not feel okay. #wpath2018
Coleman: All of the committee chapters are reviewed by all of the committee members. Looking to global chapter to provide overview. Forming advisory committee to represent regions of the world. Do hear your challenge and we're doing our best. #wpath2018
Audience comment on intersex chapter: WPATH has no position on intersex. Intersex children subjected to genital mutilation and sterilisation without informed consent across world, including Western world. WPATH needs to take a stand on this. Sign Yogyakarta Principles. #wpath2018
Again, standing ovation that looks to me primarily intersex and trans people. #wpath2018
Coleman: We are wrestling with this [intersex chapter], how to mesh scientific evidence with human rights perspective.

From floor: "This is a human rights violation!" #wpath2018
Comment from South African practitioner: Professionals from Africa excluded from your committees. We do exist and our voice needs to be heard. #wpath2018
Mauro Cabral from floor. When WPATH decided to come to Argentina, with the most progressive gender identity law in the world, I was excited. But we could only talk among selves. You to this country because of the weather, steak and wine, but not to learn from us. #wpath2018
Cabral: There is a line being drawn on intersex issues. You need to take a stand. Are you for or against what is happening? #wpath2018
Eli Coleman to Mauro Coleman: We are counting on you to advice us and ensure we are doing it right. #wpath2018
Comment from the floor: WPATH has produced a number of good statements recent on matters such as conversion therapy, "rapid onset gender dysphoria" and autogynephilia. Important in context of Trump administration in US. Will this be reflected in Standards of Care? #wpath2018
Eli Coleman: I'm glad you recognise the importance of these statements. They will be reflected in the Standards of Care. #wpath2018
Question about global education initiative and accreditation. People have been involved in culturally appropriate training for years around the world. If they are required accreditation from WPATH this can cause barriers to educators outside US. #wpath2018
Jamison Green takes to the stage to answer this question. This certification is a member benefit. We are very clear of this. People can take the course without accreditation. We absolutely object to requirement for WPATH certification for professionals to do their job. #wpath2018
We're getting a passionate back-and-forth now about certification and accreditation and the role of WPATH in this. #wpath2018
Comment on floor from hijra woman. Disturbed by language of eunuch chapter. "Enlighten me - how does this chapter on eunuchs speak to transgender?"

Coleman: We're aware this is a problem and considering it. But it's the working term. Eunuch chapter lead not here. #wpath2018
Question about language of systematic review. How are these reviews taking place?

Coleman: It's about asking the right question and finding out what evidence is out there. One part of the process. (this is fairly technical, not easy to summarise) #wpath2018
Cianán Russell from the floor commenting on potential gatekeeping dogwhistles in adult care chapter draft. Arguing that details not consistent with ICD-11.

Coleman: All I can say is we're talking about this a lot and it's a big issue.
Coleman concludes session. We're all basically interested in the same thing, and we need to work on this process together. #wpath2018
WPATH closing ceremony happening now. Gail Knudson being presented with a plaque to thank her for her service to the board. Vin Tangpricha being welcomed as new President. #wpath2018
And that's it! Where's the next conference, someone yells from the floor? Tangpricha answers that we don't know yet. #wpath2018

There is a business meeting for WPATH members at 1pm, and then I'm done here for the day.
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