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

• Åtta bedömare – en barnhormonläkare, plastikkirurg, barnläkare, allmänläkare, psykolog, psykiater och två riktlinjeexperter – bedömde var och en sex kapitel i WPATH:s riktlinjer på egen hand.
• Vården i utvecklandet av rekommendationerna fick 39–47 % poäng över kapitlen; hur evidensen söktes och valdes fick bara cirka 1,5 till 2,5 av 7.
• Praktisk användbarhet fick lägst poäng med 28–40 %, och planerna för att kontrollera hur rekommendationerna fungerar i praktiken fick 1 till 1,5 av 7.
• Oberoende fick 43–44 %, eftersom det var oklart hur finansierares inflytande och intressekonflikter hanterades.
• Den övergripande kvaliteten bedömdes till cirka 3,5 till 4 av 7 för varje kapitel (tonåringar, barn, hormoner, psykisk hälsa, vård i primärvården och kirurgi).
• Endast två av åtta bedömare skulle rekommendera kapitlen oförändrade; tre skulle rekommendera dem med ändringar och tre skulle inte rekommendera dem.
• Finansiering: studien finansierades av SEGM, som enligt författarna inte hade någon roll i dess utformning, analys eller skrivande. Huvudförfattaren har konsultat åt SEGM, och varje kliniker som bedömde betalades 1 500 USD för cirka 30–40 timmars arbete. Ingen annan finansiering redovisas.

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.