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

• Acht beoordelaars – een kinderhormoonarts, plastisch chirurg, kinderarts, huisarts, psycholoog, psychiater en twee richtlijnspecialisten – beoordeelden elk zes hoofdstukken van de WPATH-richtlijnen onafhankelijk.
• De zorgvuldigheid bij het ontwikkelen van het advies scoorde 39–47% over de hoofdstukken; het zoeken en selecteren van bewijs scoorde slechts ongeveer 1,5 tot 2,5 op 7.
• Praktische bruikbaarheid scoorde het laagst met 28–40%, waarbij plannen om te controleren hoe het advies in de praktijk werkt, werden beoordeeld met 1 tot 1,5 op 7.
• Onafhankelijkheid scoorde 43–44%, omdat onduidelijk was hoe de invloed van financiers en belangenverstrengeling werden behandeld.
• De algehele kwaliteit werd voor elk hoofdstuk (tieners, kinderen, hormonen, geestelijke gezondheid, huisartsenzorg en chirurgie) beoordeeld met ongeveer 3,5 tot 4 op 7.
• Slechts twee van de acht beoordelaars zouden de hoofdstukken ongewijzigd aanbevelen; drie zouden ze met wijzigingen aanbevelen en drie zouden ze niet aanbevelen.
• Financiering: de studie werd gefinancierd door SEGM, waarvan de auteurs zeggen dat het geen rol speelde in het ontwerp, de analyse of het verslag. De hoofdauteur heeft voor SEGM geconsulteerd, en elke klinische beoordelaar kreeg US$ 1.500 voor ongeveer 30–40 uur werk. Er wordt geen andere financiering vermeld.

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.