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

• Retningslinjen har 18 kapitler og 119 endelige forfattere, valgt blant WPATH-medlemmer pluss 16 personer fra eksterne grupper, og erstatter versjonen fra 2012.
• Rådene ble vedtatt i avstemningsrunder som krevde minst 75 % enighet og ble merket bare «anbefaler» eller «foreslår», uten å si hvor sterk evidensen var for hvert enkelt.
• Tenåringskapittelet sier at en full, nøye gjennomgang av behandlingsresultater hos tenåringer «ikke er mulig», og gir i stedet en kort generell oversikt.
• For tenåringer krever den en grundig vurdering og «flere år» med vedvarende kjønnsplager før behandlinger som er vanskeligere å reversere, men setter ingen minstealdre bortsett fra å fraråde operasjon for å lage penis før 18 år.
• Et utkast fra desember 2021 hadde foreslått minstealdre på 14 år for hormoner, 15 for brystfjerning, 16 for brystimplantater og ansiktskirurgi og 17 for genital kirurgi. Disse ble fjernet før publisering.
• Nye kapitler dekker ikke-binære og personer som identifiserer seg som evnukker, inkludert tilgang til kastrering for dem.
• Uavhengige vurderinger med et standardverktøy for å vurdere retningslinjer ga den lave skårer: omtrent 35 % for hvor omhyggelig den ble laget i York-gjennomgangen for Englands Cass-rapport, og 39–47 % for omhyggelighet og 43–44 % for uavhengighet i en vurdering i 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.