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

• 這份指引有 18 章、119 位最終作者，從 WPATH 會員加上 16 位外部團體人士中挑選，並取代 2012 年的版本。
• 建議是經由至少需要 75% 同意的投票回合達成共識，並只標示為「建議」或「提議」，沒有說明每項建議的證據有多強。
• 青少年章節表示，對青少年治療結果進行完整、仔細的審查「不可能」，改為提供簡短的一般概述。
• 對於青少年，它要求在採取較難逆轉的治療之前，要徹底評估並有「數年」持續的性別困擾，但除了建議 18 歲前不要做陰莖建造手術外，沒有設定最低年齡。
• 2021 年 12 月的草案曾提議荷爾蒙最低年齡為 14 歲、乳房切除為 15 歲、隆乳和臉部手術為 16 歲、生殖器手術為 17 歲；這些在發表前被刪除。
• 新章節涵蓋非二元性別者以及自認為閹人的人，包括為他們提供閹割的管道。
• 使用標準指引評分工具的獨立檢查給它的評分偏低：在為英格蘭 Cass 檢討報告所做的約克回顧中，其制定的嚴謹度約為 35%，在 2026 年的檢查中，嚴謹度為 39–47%，獨立性為 43–44%。

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.