Summary

As part of England's Cass Review, researchers at the University of York searched for every guideline or guidance document on caring for under-18s with gender dysphoria (distress about one's sex) and rated their quality using a standard checklist. They found 23 documents published between 1998 and 2022. Most scored poorly on how carefully they were developed, how usable they were, and independence from their makers. Few were built on careful reviews of the evidence, and it was often unclear how advice was reached. Guidelines from WPATH and the Endocrine Society influenced most others, so guidelines largely cited each other. Only Sweden's and Finland's evidence-based guidelines were recommended by all three raters. The review followed a plan registered in advance, but rating guidelines involves judgement, and critics dispute how the Cass reviews were framed.

Key findings

• Gjennomgangen fant 23 retningslinjer eller veiledningsdokumenter (4 internasjonale, 3 regionale, 16 nasjonale) publisert mellom 1998 og 2022.
• De fleste skåret godt på å forklare formålet sitt, men dårlig på hvor nøye de var utviklet, hvor brukbare de var og uavhengigheten deres.
• Bare seks dokumenter skåret over 30 % for nøye utvikling. WPATHs retningslinjer fra 2022 skåret 35 % og Endocrine Societys retningslinje fra 2017 42 %.
• Bare Sveriges (2022) og Finlands (2020) retningslinjer skåret over 50 % for nøye utvikling og ble anbefalt for bruk av alle tre vurderingspersonene.
• Ti retningslinjer involverte pasienter eller deres representanter, men bare to sa at de spurte barn, tenåringer eller foreldre direkte.
• WPATH- og Endocrine Society-veiledning dannet grunnlaget for det meste av nasjonal og regional veiledning, og de to gruppene er knyttet sammen gjennom felles sponsing.
• Forfatterne konkluderer med at det meste av veiledningen mangler en uavhengig, evidensbasert tilnærming, og at tjenester bør huske dette før de støtter seg på den.

Abstract

BACKGROUND: Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. There are various guidelines outlining approaches to the clinical care of these children and adolescents. AIM: To examine the quality and development of published guidelines or clinical guidance containing recommendations for managing gender dysphoria/incongruence in children and/or adolescents (age 0-18). A separate paper reports the synthesis of guideline recommendations. METHODS: A systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality. RESULTS: Twenty-three guidelines/clinical guidance publications (1998-2022) were identified (4 international, 3 regional and 16 national). The quality and methods reporting in these varied considerably. Few guidelines systematically reviewed empirical evidence, and links between evidence and recommendations were often unclear. Although most consulted with relevant stakeholders, including 10 which involved service users or user representatives, it was often unclear how this influenced recommendations and only two reported including children/adolescents and/or parents. Guidelines also lacked clarity about implementation. Two international guidelines (World Professional Association for Transgender Health and Endocrine Society) formed the basis for most other guidance, influencing their development and recommendations. CONCLUSIONS: Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. This should be considered when using these to inform service development and clinical practice. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Conclusion

Most clinical guidance for managing children and adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. The WPATH and Endocrine Society international guidelines, which like other guidance lack developmental rigour and transparency, have dominated the field and are linked through co-sponsorship; healthcare services and professionals should take into account the poor quality and inter-related nature of published guidance when using it to inform service development and clinical practice.