Nine out of ten: how conflicts of interest shaped gender care guidelines

Two of the most influential guidelines for gender care for children and adolescents — those of the American Endocrine Society and WPATH (World Professional Association for Transgender Health) — were written by panels in which almost everyone had a stake in the outcome. That is not the conclusion of an outside critic, but of Richard Santen, who himself served as president of the Endocrine Society for many years. His count: 9 out of 10 authors of the Endocrine Society document and 117 out of 121 authors of the WPATH Standards of Care had what he calls an “intellectual conflict of interest” — they had advocated for, worked on or built their careers around the affirmative treatment model that the guideline was meant to support.

What Santen is actually claiming

According to reporting by Gender Clinic News (Bernard Lane, September 23, 2026), Santen describes the Endocrine Society and WPATH committees as “stacked” with members who were already convinced of the affirmative approach — unlike the Finnish and Swedish guideline committees, which he says were not. That stacking, he argues, helps explain why guidelines from countries examining similar studies and the same underlying evidence arrive at completely opposing recommendations: while Finland and Sweden became more cautious about puberty blockers and hormones after conducting their own systematic reviews, the Endocrine Society and WPATH continued to support the affirmative model.

An intellectual conflict of interest is harder to pin down than a financial one — there is no payment to trace and no amount to cite. But the pattern can still be counted: when a panel is made up of people who have spent years advocating for one particular treatment approach, no pressure is needed to produce a predictable outcome. The outcome is already embedded in the panel’s composition.

The contrast: how the Cass Review did things differently

The British Cass Review, the four-year independent investigation into gender care for minors in England led by paediatrician Hilary Cass, took a different approach: independent methodologists with no direct clinical involvement in gender care assessed the evidence, separately from anyone professionally or activistically involved in the field. The outcome differed fundamentally from that of the Endocrine Society and WPATH — the Cass Review concluded that the scientific basis for puberty blockers and hormone treatment in young people is “remarkably weak.” The Finnish and Swedish health authorities reached the same conclusion — weak, uncertain evidence — after conducting their own independent reviews.

The pattern, then, is not that one side has science and the other has ideology. The pattern is that institutions using independent assessors with no stake in the matter arrive at cautious conclusions, while institutions with panels full of interested parties confirm existing practice. That difference in the composition of the committee deserves just as much attention as the difference in the conclusions — because the former explains the latter.

Why this is about more than the United States

The WPATH Standards of Care are cited worldwide as the international professional standard, including by Dutch and Flemish healthcare providers and by organisations that have broadened their focus to the gender agenda. A guideline that serves as an authority worldwide bears a greater responsibility to be developed independently than a local advisory document. If the foundation of that authority — nine out of ten authors having a personal stake in the outcome — is itself called into question, then the basis of the entire chain of translated guidelines, training programmes and treatment protocols that rely on it is called into question as well.

That a guideline is created by people without independent distance from the subject is precisely the problem also identified by critics of the Dutch Protocol: an intensivist recently pointed out that ideology carries more weight than evidence in Dutch transgender care. It is the same question, time and again: who selects the committee, and what can that committee still assess objectively?

What this is not

Santen’s count is not proof that individual authors acted dishonestly, nor does this article claim that they did. An intellectual interest is not fraud — it is an understandable, human tendency to confirm a position you have believed in for years. But that is precisely why procedures for independent review exist: not to distrust individuals, but to prevent an entire guideline from becoming the sum of everyone’s personal convictions. The fact that legislation and policy around gender are being reconsidered elsewhere in Europe as well shows that this question has long ceased to be solely American or British.

Sources

Bernard Lane, “Biased brains”, Gender Clinic News, September 23, 2026: https://www.genderclinicnews.com/p/biased-brains. Includes Richard Santen’s (former president of the Endocrine Society) count of conflicts of interest among the authors of the Endocrine Society guideline (9/10) and the WPATH Standards of Care (117/121), as well as the comparison with the independent structure of the British Cass Review.