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

• 八位评审员（包括一名儿童内分泌医生、整形外科医生、儿科医生、全科医生、心理学家、精神科医生及两位指南专家）分别对WPATH指南的六个章节进行了独立评分。
• 指南建议制定过程的严谨性在各章节中得分在39%至47%之间；证据检索与筛选环节的得分仅为7分制下的1.5至2.5分。
• 实践适用性得分最低（28%至40%），其中对建议实际应用效果的监测计划评分仅为1至1.5分（满分7分）。
• 独立性得分为43%至44%，因未能明确处理资助方影响及利益冲突问题。
• 所有章节（涉及青少年、儿童、激素治疗、心理健康、全科诊疗及手术）的整体质量评分均为7分制下的3.5至4分。
• 八位评审员中仅两人推荐直接采用指南章节；三人建议修改后采用，三人不予推荐。
• 资金声明：本研究由SEGM资助，作者声明该组织未参与研究设计、数据分析及论文撰写。第一作者曾为SEGM提供咨询服务，每位临床评审员为30-40小时工作量获得1500美元报酬。无其他资金声明。

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.