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

• Ocho evaluadores: un endocrinólogo pediátrico, un cirujano plástico, un pediatra, un médico de familia, un psicólogo, un psiquiatra y dos expertos en guías clínicas, calificaron individualmente seis capítulos de las directrices de WPATH.
• El cuidado en el desarrollo de las recomendaciones obtuvo una puntuación del 39-47% entre capítulos; la búsqueda y selección de evidencia puntuó solo entre 1.5 y 2.5 sobre 7.
• La utilidad práctica obtuvo la puntuación más baja (28-40%), con los planes para verificar la aplicación de las recomendaciones en la práctica calificados entre 1 y 1.5 sobre 7.
• La independencia obtuvo un 43-44%, debido a la falta de claridad en el manejo de la influencia de los financiadores y los conflictos de interés.
• La calidad general se calificó entre 3.5 y 4 sobre 7 para cada capítulo (adolescentes, niños, hormonas, salud mental, atención primaria y cirugía).
• Solo dos de los ocho evaluadores recomendarían los capítulos sin cambios; tres los recomendarían con modificaciones y tres no los recomendarían.
• Financiación: el estudio fue financiado por SEGM, que según los autores no participó en su diseño, análisis o redacción. El autor principal ha sido consultor de SEGM, y cada evaluador clínico recibió US$1,500 por aproximadamente 30-40 horas de trabajo. No se declara otro financiamiento.

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.