Summary

WPATH's Standards of Care 8 (2022) is the world's most influential guideline for transgender healthcare. In this study, eight trained raters, doctors and therapists from several fields plus two experienced guideline experts, scored six chapters relevant to young people using the standard checklist for judging how well guidelines are made. The chapters scored poorly on rigour (how evidence was searched for, chosen and linked to advice), on practical usefulness and on independence from funders and conflicts. Overall quality was rated about 3.5 to 4 out of 7. Raters split evenly between recommending the chapters, recommending them with changes, and rejecting them. The findings echo the Cass Review's earlier rating. The study was funded by SEGM, and only eight raters took part.

Key findings

• Eight raters, a children's hormone doctor, plastic surgeon, children's doctor, family doctor, psychologist, psychiatrist and two guideline experts, each scored six chapters of WPATH's guidelines on their own.
• Care in developing the advice scored 39–47% across chapters; how the evidence was searched for and chosen scored only about 1.5 to 2.5 out of 7.
• Practical usefulness scored lowest at 28–40%, with plans for checking how the advice works in practice rated 1 to 1.5 out of 7.
• Independence scored 43–44%, because it was unclear how funders' influence and conflicts of interest were handled.
• Overall quality was rated about 3.5 to 4 out of 7 for every chapter (teenagers, children, hormones, mental health, family-doctor care and surgery).
• Only two of eight raters would recommend the chapters unchanged; three would recommend them with changes and three would not recommend them.
• Funding: the study was funded by SEGM, which the authors say had no role in its design, analysis or write-up. The lead author has consulted for SEGM, and each clinician rater was paid US$1,500 for about 30–40 hours of work. No other funding is declared.

Abstract

In 2022, the World Professional Association for Transgender Health (WPATH) released their guidelines, Standards of Care Version 8 (SOC8), which have been regarded as establishing standards for the management of transgender patients. To conduct a quality assessment of the WPATH's SOC8 using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, we recruited a diverse group of international health professionals as assessors, including six clinicians and two guideline methodologists, who were trained in the AGREE II tool and underwent a calibration exercise. They independently assessed six SOC8 chapters: adolescents, children, hormone therapy, mental health, primary care, and surgery. We summarized the ratings across assessors for all items to present the strengths and limitations of the guidelines. The evaluations identified that the SOC8 chapters had limitations in the AGREE II domains of applicability (ranging from 28% to 40% across chapters), editorial independence (ranging from 43% to 44% across chapters), and rigor of development (ranging from 39% to 47% across chapters). On a scale of 1 to 7 (7 = highest quality), the median overall quality score was 3.5 to 4 for all chapters. Two of eight assessors recommended using the guideline chapters, while three recommended use with modification, and three recommended not to use the reviewed guideline chapters due to methodological concerns. Evidence-based guidelines addressing the needs of transidentified people are urgently needed, but it is imperative that healthcare providers, researchers, and policymakers recognize and address the limitations present in these six SOC8 chapters.

Conclusion

The assessment found that WPATH's SOC8 guidelines have limitations in scientific and methodological rigour, applicability, and transparency in managing competing interests. Evidence-based guidelines addressing the needs of trans-identified children and adolescents are urgently needed, but uncritical adoption or endorsement of WPATH's guidelines may result in a disservice or even harm to this vulnerable population. Healthcare providers, researchers and policymakers should recognise and address the limitations of SOC8.