By Aly W. | First published May 1, 2020 | Last modified February 16, 2021
Forgive me if i’m the 10,000th person to ask about Dr. Will Powers or bitch about WPATH, i’m new here. Comment if this is the case and i’ll take it down, but aside from on r/DrWillPowers it seems like noone is talking about how wpath is outdated, unsafe, and has a ton of room for improvement in the field of HRT. I’m just trying to get a bead on how unsafe or bad of an option WPATH’s standard of care (chosen medications/dosages/timeline of treatment) is compared to something more experimental like this.
There is a simple reason for this. It’s because they aren’t. That they are is a falsehood.
As others have described, “WPATH” doesn’t provide recommendations or guidelines on hormone therapy. What Powers is referring to are essentially the Endocrine Society’s transgender hormone therapy guidelines (Hembree et al., 2009; Hembree et al., 2017) and the transgender medical community in general. The fact that Powers and his supporters apparently aren’t aware of this and what they’re attacking should tell you a thing or two about the reliability of the claim. If you want to know the truth about the guidelines, I recommend reading them for yourself (see here and here).
Powers doesn’t like “WPATH” because the transgender medical establishment largely disapproves of him and his methods. In professional and research circles he isn’t taken seriously (although there are some exceptions among clinicians). This is based on my personal experience with these circles. There are a variety of reasons that the transgender medical community hasn’t been impressed by Powers. One is that his claims are unpublished and anecdotal. Another is that his methods largely haven’t been evaluated in actual clinical studies in transgender people, for instance in terms of effectiveness and safety. A third reason is Powers’s lack of credentials and professional engagement. He’s a small-town family-medicine clinician and he doesn’t attend any of the transgender medicine conferences. Moreover, he doesn’t have specialized training in endocrinology and he isn’t a research clinician at say a university research hospital. It wouldn’t surprise me if Powers has no research experience at all. Powers doesn’t get the approval or recognition he wants from the transgender medical establishment so he’s turned against it. And the medical community ignores him and doesn’t bother to respond for all of the reasons above. At least at this time, Powers isn’t someone of importance in the transgender medical establishment—a fact that he himself has made clear in places (Reddit; Reddit). Consequent to his opposition towards “WPATH”, it’s my opinion that Powers has helped contribute a great deal of discord and mistrust between transgender people and their medical providers.
Normally I don’t give consideration to personal qualifications and instead evaluate peoples’ claims based solely on their veracity. And I’m not saying any of what I’m saying here to needlessly disparage Powers. But rather to illuminate matters because I think that it’s important for people to understand in light of the situation at hand. Powers has widespread popularity in the transgender community and he and his supporters are falsely disparaging the general transgender medical establishment. Transgender people need to know who and what Powers really is and why the real situation is so far from the way that he portrays it. Powers paints a picture as if transgender people have been forgotten by the medical community and he’s the only person trying to innovate in our care. But this is merely part of a deceptive narrative and in reality there’s a large international research community of highly competent professionals dedicated to advancing our care. These researchers publish amazing studies and reviews on transgender hormone therapy every year. We’ve routinely posted and covered these publications in r/MtFHRT (e.g., Meyer et al., 2020; Angus et al., 2019; Reisman et al., 2019; Jain et al., 2019; Neyman et al., 2019; Leinung et al., 2018). In contrast to Powers these researchers don’t seek the spotlight and get little notice or credit for their work. Why Powers feels the need to do so is an interesting character study for another day (Reddit—note that I’m not referring to his autism). I think it’s also important for people to ask themselves why Powers doesn’t simply join the establishment and attempt to change it from the inside with research and publications. It’s because that isn’t an easy or efficient way to get the idolization he seems to want—which he readily receives right now with very little effort from his many transgender followers—and he currently doesn’t have that level of professional ability.
Powers is very unscientific and holds many poorly supported beliefs about sex-hormone endocrinology. Moreover, he spreads these ideas widely throughout the transgender community due to his prominent online presence. Powers does have a few good ideas, and I’ll get to those. But having a few decent ideas doesn’t mean that the rest of his claims are good—far from it. Many of Powers’s ideas in general are simply false (Aly W., 2019). They are based on flawed surface reading of the literature, poorly informed layperson theories, and/or unreliable anecdotal observations in lieu of actual scientific data. This applies particularly to his claims about breast development in transfeminine people. See here, here, here, here, and here for some exposition of this. Furthermore, Powers sticks with these ideas even when shown evidence to the contrary. He claimed here to have changed a great deal in response to my fact check of his lecture. In reality however, he changed very little in his presentation when he released the next version. What was said here (2nd paragraph) mirrors my own impression.
With all of that said, I actually agree with a few of Powers’s ideas. Examples include the use of estradiol ester injections (in appropriate individuals and at reasonable doses), bicalutamide as an antiandrogen in transfeminine people (with appropriate liver monitoring), progestogens besides cyproterone acetate (e.g., rectal progesterone) for testosterone suppression (for a limited duration), and rectal progesterone instead of oral progesterone (when progesterone is employed). Tangentially, I find it disagreeable when Powers brands these ideas as the “Powers method” and implies that he originated them however. These ideas were around long before he discovered them, and the real clinicians and transgender people who developed them get little credit for doing so. Per Juno Krahn of the Trans HRT Facebook group—”most steps to better HRT he derived from our forum with very little attribution”. My own physician was also using approaches like estradiol ester injections and bicalutamide in 2015—well before Powers was. I do have to give Powers some credit for helping to popularize the modalities in question however. Although I believe that these approaches are indeed good ideas, they haven’t been widely accepted in the transgender medical establishment at this time. I think the key reason for this is that they haven’t yet been properly articulated. Theory and data extrapolable from other patient populations support these approaches as effective and acceptably safe modalities for transfeminine people with potential advantages over conventional medication regimens. Others and I are personally working towards explanation and promotion of these therapies in the transgender medical community. Unfortunately however, and in a notable irony, they may be seen as “Powers” ideas and this might ultimately make it harder for them to be accepted.
Contrary to what Powers and his supporters claim, “WPATH”—or more accurately the Endocrine Society’s guidelines—aren’t outdated or unsafe. The latest version of the Endocrine Society’s guidelines were published in 2017 and were up-to-date with all of the latest research. These guidelines are based on actual clinical studies in transfeminine people. As alluded to above, I do agree that there are improvements to be made in the hormonal regimens used in the transgender medical community. Inadequate testosterone suppression with oral estradiol and spironolactone in many transfeminine people as in the United States has been demonstrated in multiple recent studies (Leinung et al., 2018; Liang et al., 2018) and is one thing that needs to be improved upon. The Endocrine Society guidelines also very much need to lower their dose recommendations for cyproterone acetate (Aly W., 2019; Aly W., 2020). But that’s similarly based on new data and will almost certainly happen with the next version. Overall, with a few caveats—namely those just mentioned—the transgender medical establishment approaches are effective and safe. Moreover, in spite of what Powers himself claims, there are no data at present showing that what he does clinically provides any better feminization or breast development than conventional regimens. Anecdotes and repeated assertions are not sufficient to demonstrate this, only appropriately designed controlled clinical studies.
As described already, I do think that certain approaches Powers employs—namely estradiol ester injections, bicalutamide, and rectal progesterone—are useful alternatives for transfeminine hormone therapy. And these therapeutic options may indeed be advantageous relative to conventional choices like oral estradiol plus spironolactone or cyproterone acetate. But more studies and characterization of these approaches are needed in transfeminine people before they’ll be widely accepted. Unfortunately I wouldn’t look to Powers for such studies however. It’s unlikely that he’ll deliver on his research expectations. His true research plans appear to be limited to small case series (Reddit; Reddit)—which amount to little more than published anecdote. In any case, hopefully in the near future, I expect that there will be more publications on the approaches in question from others besides Powers.
Update 2: As a result of this comment, Powers has posted a thread on Reddit here updating his positions on “WPATH” and asking his supporters to stop attacking it. A welcome change, in my opinion.