Summary

WPATH's Standards of Care version 8 (2022) is the most widely cited guideline in transgender medicine, used by clinics, insurers and courts. Written by 119 mostly WPATH-member authors, it backs access to hormones and surgery for adults and, after assessment, for teenagers. It is based on expert agreement, not a careful, complete review of the evidence. It says such a review for teens was "not possible", and it does not say how strong the evidence is behind each piece of advice. Independent checks using a standard tool for judging guidelines rated how carefully it was made, and how independent it was, as low. Court documents later showed that minimum ages were removed at the last minute, after pressure from the American Academy of Pediatrics and US health officials. They also showed WPATH controlled whether the evidence reviews it had ordered from Johns Hopkins got published.

Key findings

• La linea guida ha 18 capitoli e 119 autori finali, scelti tra i membri della WPATH più 16 persone di gruppi esterni, e sostituisce la versione del 2012.
• Le indicazioni sono state concordate con turni di votazione che richiedevano almeno il 75% di consenso ed etichettate solo come «si raccomanda» o «si suggerisce», senza dire quanto fossero solide le prove per ciascuna.
• Il capitolo sugli adolescenti dice che una revisione completa e accurata dei risultati dei trattamenti negli adolescenti «non è possibile» e offre invece una breve panoramica generale.
• Per gli adolescenti chiede una valutazione approfondita e «diversi anni» di disagio di genere persistente prima di trattamenti più difficili da invertire, ma non fissa età minime, se non sconsigliando la chirurgia di costruzione del pene prima dei 18 anni.
• Una bozza di dicembre 2021 aveva proposto età minime di 14 anni per gli ormoni, 15 per l'asportazione del seno, 16 per le protesi mammarie e la chirurgia del viso e 17 per la chirurgia genitale; sono state eliminate prima della pubblicazione.
• Nuovi capitoli riguardano le persone non binarie e le persone che si identificano come eunuchi, compreso l'accesso alla castrazione per loro.
• Verifiche indipendenti con uno strumento standard di valutazione delle linee guida le hanno assegnato un punteggio basso: circa il 35% per l'accuratezza con cui è stata redatta nella revisione di York per la Cass Review inglese, e il 39–47% per l'accuratezza e il 43–44% per l'indipendenza in una verifica del 2026.

Abstract

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Conclusion

The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of transgender and gender diverse people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions, the criteria for gender-affirming medical interventions are clinical guidelines, and individual health care professionals and programs may modify them in consultation with the TGD person. Statement 2.1 recommends that health care systems provide medically necessary gender-affirming health care. For adolescents, SOC-8 recommends a comprehensive biopsychosocial assessment and several years of persistent gender incongruence before less reversible treatments, but sets no minimum ages except advising against phalloplasty under 18.