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

• Oito avaliadores – um endocrinologista pediátrico, um cirurgião plástico, um pediatra, um médico de família, um psicólogo, um psiquiatra e dois especialistas em diretrizes – avaliaram individualmente seis capítulos das diretrizes da WPATH.
• O cuidado no desenvolvimento das recomendações obteve pontuação de 39–47% entre os capítulos; a busca e seleção de evidências pontuou apenas cerca de 1,5 a 2,5 em 7.
• A utilidade prática teve a pontuação mais baixa, de 28–40%, com os planos para verificar a aplicação das recomendações na prática avaliados em 1 a 1,5 em 7.
• A independência obteve 43–44%, por não estar claro como a influência dos financiadores e os conflitos de interesse foram tratados.
• A qualidade geral foi avaliada em cerca de 3,5 a 4 em 7 para cada capítulo (adolescentes, crianças, hormônios, saúde mental, atendimento em atenção primária e cirurgia).
• Apenas dois dos oito avaliadores recomendariam os capítulos sem alterações; três os recomendariam com mudanças e três não os recomendariam.
• Financiamento: o estudo foi financiado pela SEGM, que, segundo os autores, não teve qualquer papel no seu desenho, análise ou redação. O autor principal prestou consultoria para a SEGM, e cada avaliador clínico recebeu US$ 1.500 por cerca de 30 a 40 horas de trabalho. Nenhum outro financiamento é declarado.

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.