By Aly W. | First published May 1, 2020 | Last modified January 1, 2022
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is the case and i’ll take it down, but aside from on r/DrWillPowers it seems like noone is talking about how wpath is outdated, unsafe, and has a ton of room for improvement in the field of HRT.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’s a simple reason for this. It’s because they aren’t. And the idea that they are is a fabrication.
As others have described, although the World Professional Association for Transgender Health (WPATH) publishes the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, they don’t provide recommendations or guidelines on hormone therapy at this time (Coleman et al., 2012). What Powers is referring to are essentially the Endocrine Society’s transgender hormone therapy guidelines (Hembree et al., 2009; Hembree et al., 2017) and hormone therapy practices in the transgender medical community in general. The fact that Powers and his supporters apparently aren’t aware of this and exactly what they’re attacking should tell you a thing or two about the reliability of their claims. If you want to know the truth about the guidelines, I recommend reading them for yourself (see the preceding links as well as here and here for relevant sections and excerpts).
Powers and his supporters don’t like what they are referring to as “WPATH” because the transgender medical community largely disapproves of him and his methods. In professional and research circles, he isn’t taken seriously. There are a variety of reasons that the 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 One is that his claims are unpublished and anecdotal.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 critical issues like effectiveness and safety. A third reason is Powers’s lack of credentials and professional engagement. He’s a family medicine clinician from a small suburban town in Michigan who doesn’t attend any of the transgender medicine conferences or otherwise engage with the rest of the professional transgender health community. Furthermore, he doesn’t have training in endocrinology and he isn’t a researcher or academic. Although Powers is a physician, it wouldn’t surprise me if he has no research experience at all. Powers doesn’t get the approval or recognition he wants from the transgender medical community, so he’s turned against it. And the medical community largely ignores him and doesn’t bother to respond for all of the reasons above. At least at this time, Powers isn’t an important person in the transgender medical community—a fact that he himself has made clear in places (e.g., Reddit; Reddit). Moreover, as a result of his opposition towards “WPATH”, it’s my opinion that Powers has helped foment a great deal of discord and mistrust between transgender people and their medical providers.
Normally, I try not to give consideration to personal qualifications when it comes to claims about transgender hormone therapy and instead evaluate such 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 Powers has widespread popularity in the online transgender community and he and his supporters are falsely disparaging the transgender medical community. Transgender people need to be aware of 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 transgender hormone therapy. But in reality there’s a large international research community of highly competent professionals who are working hard to improve our care. These researchers publish outstanding studies and reviews on transgender hormone therapy every year (e.g., Meyer et al. (2020), Iwamoto et al. (2019), Angus et al. (2019), Reisman et al. (2019), Jain, Kwan, & Forcier (2019), Neyman et al. (2019), and Leinung et al. (2018), among many others). My group and I have routinely posted and covered these publications on Reddit in the past. In contrast to Powers, these researchers don’t seek the spotlight and get little notice or credit from transgender people for their work. Why Powers feels the need to seek these things is an interesting character study for another day (note that I’m not alluding to his mild autism with that link but rather something else that should be readily apparent). I think it’s also important for people to ask themselves why Powers doesn’t simply join the rest of the transgender medical community and try to influence it from the inside with research and publications. It’s because that isn’t an easy or efficient way to get the appreciation 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 sort of professional capacity.
Powers is highly unscientific and holds many poorly supported beliefs about sex hormones and endocrinology. Moreover, he spreads these ideas widely throughout the online transgender community due to his prominent social media presence. Powers does have a few good ideas, and I’ll get to those. But having some decent ideas doesn’t mean that the rest of one’s claims are good. Many of Powers’s ideas are simply false. They are based on flawed surface reading of the literature, poorly informed layperson theories, and/or unreliable anecdotal observations in lieu of quality scientific data. This applies particularly to his claims about feminization and breast development in transfeminine people. See my fact check of his transgender care presentation for extensive discussion of his claims. In addition, Powers sticks with his ideas even when shown evidence that disproves them. His anecdotal observations and conjectures are apparently too compelling for him to give up. He claimed on Reddit to have changed a great deal in response to my fact check of his PowerPoint. In reality however, he changed very little when he released the next version. What was said here largely mirrors my own impression:
Re: Powers corrections. Yeah, I heard his presentation, I saw he made some corrections to it in response to some feedback and I thought.. Great, he really seems to care. I read over the presentation again and the differences seemed really minor, so I wasn’t sure what those corrections were. Then I read the feedback and, well… he didn’t correct shit.
With all of that said, I actually agree with a few of Powers’s ideas. Examples of these ideas include:
- Use of high-dose estradiol ester injections for testosterone suppression
- Bicalutamide as an alternative to spironolactone for testosterone blockade
- Rectal progesterone as an alternative to cyproterone acetate for testosterone suppression
- And rectal progesterone instead of oral progesterone in general when progesterone is used
I support the use of these approaches because testosterone suppression is often inadequate in transfeminine people and this is likely to adversely impact therapeutic outcomes. Morever, conventionally employed options, like spironolactone, cyproterone acetate, and oral progesterone, have problems with efficacy, safety, and/or availability. However, whereas Powers places little in the way of limits on his use of the above-listed approaches, I believe that there should be important restrictions and stipulations in terms of their use. Specifically, (1) high-dose estradiol ester injections should only be used at reasonable and limitedly high doses (e.g., the equivalent of perhaps 3.5 mg/5 days, reaching mean estradiol levels of no more than around 300 pg/mL on average—notably far below the 6–9 mg/5 days that Powers himself uses—e.g., Reddit, Reddit); (2) bicalutamide should only be used with careful and regular liver monitoring; (3) high-dose estradiol as well as progestogens should only be used in appropriately selected individuals at low risk for relevant complications and for a limited duration; and (4) these approaches should only be used when other, better options like GnRH modulators are inaccessible (due to e.g. cost, coverage, or availability). The reason for these restrictions is that these approaches all have significant risks—which is notably why they have not been more adopted by the transgender medical community at this time. Nonetheless, I believe that the potential benefits of these approaches when used appropriately outweigh the potential harms. In contrast, and concerningly, Powers provides these approaches indiscriminately to all of his transfeminine patients—and frequently uses all three of them in combination.
My perception as to why these approaches haven’t been more accepted in the transgender medical community at this time is that they haven’t been properly articulated yet. Theory and data extrapolable from other patient populations support these approaches as effective and reasonably safe options for transfeminine hormone therapy with advantages over conventional therapies provided that they are used appropriately and better alternatives like GnRH modulators are not possible. There are people who are working towards explanation and promotion of these approaches for use in transfeminine hormone therapy and I hope that we will see more on them in the published literature in the future.
This is tangential, but I find it annoying when Powers brands the preceding approaches as the “Powers method” and inadvertently implies that he developed them. These ideas were around long before he was introduced to them, and the real clinicians—and transgender people—who originated them get little credit for doing so. Per Juno Krahn of the Trans HRT Facebook group on Powers—”most steps to better HRT he derived from our forum with very little attribution” (personal communication, with permission). Moreover, my own physician was using approaches like high-dose parenteral estradiol and bicalutamide in 2015, well before Powers was. I do have to give Powers some credit for helping to popularize the approaches in question however. But unfortunately, and in a notable irony, with untold numbers of Powers followers banging their hormone therapy doctors over the head with his transgender care presentation and aggressively demanding the “Powers method”, these approaches may now be seen as “Powers” ideas and this might ultimately make it harder for them to become more 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 in terms of the available research on transgender hormone therapy. 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 terms of the hormonal regimens used in the transgender medical community. Inadequate testosterone suppression (≫50 ng/dL) with estradiol and spironolactone in many transfeminine people as in the United States has been demonstrated in numerous studies (e.g., Leinung (2014), Leinung et al. (2018), Liang et al. (2018), Angus et al. (2019), Jain, Kwan, & Forcier (2019), Sofer et al. (2020), and Burinkul et al. (2021)) and is one thing that is in major need of improvement. 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 most certainly happen with the next version. Overall, with a few caveats—namely those just mentioned—the hormone therapy approaches used in the transgender medical community are effective and safe. Moreover, in spite of what Powers himself claims, there are no data at present showing that what he does clinically—beyond achieving proper testosterone suppression—provides any better feminization or breast development than conventional regimens. Anecdotes and repeated assertions by Powers are not sufficient to demonstrate this, only rigorous and appropriately conducted clinical studies.
Once again, I do think that certain approaches that Powers employs—namely high-dose estradiol ester injections, bicalutamide, and rectal progesterone—are useful options for purposes of testosterone suppression in transfeminine people. These approaches are likely to have advantages over conventional options and to have acceptable safety when used appropriately. But more studies and exposition of these approaches for use in transfeminine hormone therapy are likely to be needed before they could be more widely adopted. Powers has claimed to be working on research and publications for years and his transgender followers have had high expectations in this regard. However, I wouldn’t look to Powers for such studies as it’s unlikely that he’ll actually deliver on these expectations. He isn’t a researcher and he doesn’t have institutional affiliation, so he doesn’t have the institutional review board (IRB) access and oversight that are required for real studies (Reddit; Reddit). His true research aspirations and publication plans appear to be limited to small case studies of three people or fewer (Reddit; Reddit), which would amount to little more than published anecdote and would hold little scientific weight. In any case, I hope to see more publications on these approaches from others besides Powers in the future.
As a result of this comment, Powers has posted here on Reddit updating his positions on “WPATH” and asking his supporters to stop attacking it. A welcome and much-needed change, in my opinion.