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

• A diretriz tem 18 capítulos e 119 autores finais, escolhidos entre membros da WPATH mais 16 pessoas de grupos externos, e substitui a versão de 2012.
• As orientações foram acordadas em rodadas de votação que exigiam pelo menos 75% de concordância e rotuladas apenas como "recomendamos" ou "sugerimos", sem dizer quão forte era a evidência para cada uma.
• O capítulo sobre adolescentes diz que uma revisão completa e cuidadosa dos resultados do tratamento em adolescentes "não é possível" e oferece, em vez disso, uma breve visão geral.
• Para adolescentes, pede uma avaliação minuciosa e "vários anos" de sofrimento de gênero duradouro antes de tratamentos mais difíceis de reverter, mas não estabelece idades mínimas, exceto aconselhar contra a cirurgia de construção do pênis antes dos 18 anos.
• Um rascunho de dezembro de 2021 havia proposto idades mínimas de 14 anos para hormônios, 15 para retirada das mamas, 16 para implantes mamários e cirurgia facial e 17 para cirurgia genital; estas foram removidas antes da publicação.
• Novos capítulos tratam de pessoas não binárias e de pessoas que se identificam como eunucos, incluindo o acesso à castração para elas.
• Avaliações independentes com uma ferramenta padrão de classificação de diretrizes deram-lhe pontuação baixa: cerca de 35% quanto ao cuidado com que foi feita na revisão de York para a Revisão Cass da Inglaterra, e 39–47% quanto ao cuidado e 43–44% quanto à independência em uma avaliação de 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.