What is WPATH and what are their guidelines?

WPATH Standards of Care are written and developed by self-appointed experts in the field, and do not use the best standards of examining evidence and writing recommendations, which introduces a high risk of bias.

Clinicians learn basics during their education and core training, but are obliged to engage in ‘continuous professional development’ (CPD) throughout their careers. Guidelines may be used to help them work in teams and keep up to date with practice. They may be local to one service or hospital, or national related to a specialty or region, or even international.

The longest standing collective authority on gender dysphoria is the World Professional Association for Transgender Health (WPATH). It is a membership organisation that began in 1979, originally called the Harry Benjamin International Gender Dysphoria Association (Devor, no date). Dr Harry Benjamin (1885-1986) was an early sexologist and endocrinologist, and considered a ‘founding father’ of the medical study of gender dysphoria, (previously known as transsexualism). WPATH develops its own policies and educational materials, writes responses to developments within transgender politics or health as an international body, and organises events. WPATH holds an annual symposium, where people interested in transgender topics gather and present papers to each other. The organisation is partnered with the academic publication International Journal of Transgender Health. 

Full professional membership of WPATH is open (for a fee) to those working in disciplines such as: medicine, psychology, law, social work, counselling, psychotherapy, nursing, family studies, sociology, anthropology, speech and voice therapy and sexology. However, non-professionals, such activists and patients, can also join as supporters (WPATH, no date a). Benefits of signing up to become a member of WPATH include being listed in their online “Find a Provider” tool, access to private discussion networks and discount entry to conferences. Members also get opportunities to become involved in WPATH educational initiatives, join task forces and contribute to their committees. WPATH members residing in Europe automatically join the European Professional Association for Transgender Health (EPATH). Similarly, WPATH members residing in the USA become automatic members of the United States Professional Association for Transgender Health (USPATH). 

In 2012, WPATH published version seven of its Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People (SOCv7). SOCv7 outlines WPATH advice for professionals regarding clinical management of people whose gender identity is mismatched with their sex, including administration of medical interventions such as hormones and surgery (Coleman et al., 2012). 

One method for evaluating the quality of a clinical practice guideline (CPG) is the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Next Steps Consortium, 2017). In a study of all international CPGs covering all aspects of transgender healthcare SOCv7 scored low. The guidance was independently rated by six reviewers, who noted the document contained no clear key recommendations and was linked to a weak evidence base (Dahlen, Connolly, Arif, M. H. Junejo, et al., 2021). However, this appeared to be similar to CPGs covering the same area of healthcare as SOCv7: “Transition-related CPGs tended to lack methodological rigour and rely on patchier, lower-quality primary research.” (Dahlen, Connolly, Arif, M. H. Junejo, et al., 2021) by comparison with World Health Organisation guidelines on blood bourne related issues which were high quality. Other authors have written that WPATH SOCv7: “remains largely based on lower-quality evidence (i.e., observational studies) and expert opinion, and with a scope that remains limited primarily to describing best practices for the diagnosis of gender dysphoria and assessing readiness and appropriateness for interventions. SOC v7 lacks any rating of the quality of the available evidence or strength of the recommendations or description of how expert contributors are selected to participate in the process of developing the guidelines.” (Deutsch, Radix and Reisner, 2016). 

SOCv7 can therefore be considered a low quality CPG, which does not reach ‘gold standard’ (Dahlen, Connolly, Arif, M. H. Junejo, et al., 2021). Despite these shortcomings, the materials produced by WPATH have been used all over the world, adapted in other guidelines and are cited in legal cases. In the UK, activism calling for widespread adoption of SOCv7 influenced the creation of NHS policies on transgender health (Gender Identity Research and Education Society, no date), such as guidance produced by the Royal College of Psychiatrists (Wylie et al., 2014).

The first iteration of the WPATH Standards of Care was released in 1979. The advice has since been updated regularly; the WPATH Board of Directors decide the timing of any revisions. For SOCv7, a work group comprising members of WPATH examined the previous version and decided where changes might be needed. Then, individual authors were appointed to review the literature for each section of the Standards of Care and publish papers in the International Journal of Transgenderism. The WPATH board appointed a revision committee and writing group, hired a technical writer and set up an international advisory committee of transgender people to comment on the drafts. The process was funded by an anonymous donor and the Tawani foundation (Coleman et al., 2012). A similar process appears to be undertaken with version eight (SOCv8), which was published in draft form for comment (WPATH, no date b). 

WPATH Standards of Care are written and developed by self-appointed experts in the field, and do not use the best standards of examining evidence and writing recommendations, which introduces a high risk of bias. These professionals are themselves interested and invested in the various medical interventions that they recommend, and in demonstrating their own authority. Such risks of bias are by no means unique to transgender health and have been noted in many other areas of medicine. Furthermore, some of the authors of the WPATH Standards of Care may be informed more by political campaigning, rather than bringing experience as healthcare professionals, academics in relevant fields or guideline methodologists. For example, Susie Green of the UK Charity Mermaids has no clinical background, but is helping to write the WPATH chapter on paediatric gender dysphoria for SOCv8. Senior healthcare professionals who are WPATH members have allegedly expressed concerns regarding the influence of activism on clinical practice in transgender health (Shrier, 2021).

Addendum
In 2022 WPATH published its Standards of Care version 8. The authors of the above referenced BMJ article wrote a letter to BMJ commenting on Soc8. They made the following comments:

WPATH claim that SoCv8 “is based upon a more rigorous and methodological evidence-based approach than previous versions.”(pS247). Although there are presentational improvements (e.g. boxed numbered recommendations), flaws remain:
• Appendix A does not address the fundamental areas requiring improvement regarding evidence and methodology that we and others identified. There are no PICO questions answered by SRs with GRADE data.
• There is no consequent, explicit linking of the evidence to recommendations.
• Each recommendation does not have an evidence grade.
• Decisions on the strength of recommendation statements, worded as “we recommend” or “we suggest”, are not open and transparent because “The balance of potential benefits and harms” are mixed with “Confidence in that balance or quality of evidence”, “Values and preferences of providers and patients” and “Resource use and feasibility”.
• It is impossible to determine which factors were more or less important when panels made their judgments.
• Such important underpinning detail ought to be clear and available to “show the workings” to others.

Further aspects are perplexing. The statement “a systematic review regarding outcomes of treatment in adolescents is not possible”(pS46) seems strange, given well-known evidence reviews exist[14,15] but are omitted from SoCv8’s references. Statement 2.1 asserts “strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments” (pS18), yet is supported by 21 references without any explanations of the papers’ context or evidentiary validity. This is unconvincing to those external audiences used to judging clinical effectiveness by quality, not quantity. 

SoCv8 is “based on the published literature (direct as well as background evidence) [and] on consensus-based expert opinion”(pS247) including a Delphi process, but evidence curation moved on long ago; WPATHs methods are prone to bias and are not “evidence-based”[16-20]. Advice to improve methods from the SoCv8 “guideline methodologist [who] assisted with the planning and development of questions and systematic reviews” may have been insufficiently appreciated. It is disappointing that our publication, conference presentation and correspondence with WPATH (Sept 30 and Oct 13 2021) remain unacknowledged, unchallenged and unaddressed.

It appears WPATH expects readers to faithfully accept potentially biased judgments of the literature rather than confidently submitting SoCv8 to open scientific scrutiny. SoCv8 could have been much better: its evidence base and recommendations cannot yet be relied upon.

References:

AGREE Next Steps Consortium (2017) The AGREE II Instrument [Electronic version]. Available at: http://www.agreetrust.org (Accessed: 14 July 2020).

Coleman, E. et al. (2012) ‘Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7’, International Journal of Transgenderism, 13(4), pp. 165–232. doi: 10.1080/15532739.2011.700873.

Coleman E, Radix AE, Bouman WP et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health 2022; 23:sup1, S1-S259. doi: 10.1080/26895269.2022.2100644

Dahlen, S., Connolly, D., Arif, I., Junejo, M., et al. (2021) AGREE II is an agreeable, accessible tool to assess the quality of trans and gender minority clinical practice guidelines, Blog BMJ Sexual & Reproductive Health. Available at: https://blogs.bmj.com/bmjsrh/2021/12/09/agree-ii-is-an-agreeable-accessible-tool-to-assess-the-quality-of-trans-and-gender-minority-clinical-practice-guidelines/.

Dahlen, S., Connolly, D., Arif, I., Junejo, M. H., et al. (2021) ‘International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment’, BMJ Open, 11(4), p. e048943. doi: 10.1136/bmjopen-2021-048943.

Sara Dahlen, Catherine Meads and Susan Bewley 2022 WPATH Standards of Care: A new edition using outdated methods weakens the trustworthiness of content. https://bmjopen.bmj.com/content/11/4/e048943.responses#wpath-standards-of-care-a-new-edition-using-outdated-methods-weakens-the-trustworthiness-of-content

Deutsch, M., Radix, A. and Reisner, S. (2016) ‘What’s in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care’, AMA Journal of Ethics, 18(11), pp. 1098–1106. doi: 10.1001/journalofethics.2016.18.11.stas1-1611.

Devor, A. (no date) History of the Association, WPATH. Available at: https://www.wpath.org/about/history.

Gender Identity Research and Education Society (no date) What We Do. Available at: https://www.gires.org.uk/what-we-do/improving-medical-care/.

Shrier, A. (2021) Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care, Common Sense with Bari Weiss Substack. Available at: https://bariweiss.substack.com/p/top-trans-doctors-blow-the-whistle.

WPATH (no date a) Membership Information, WPATH. Available at: https://www.wpath.org/MembershipInfo.

WPATH (no date b) Standards of Care version 8. Available at: https://www.wpath.org/soc8.

Wylie, K. et al. (2014) ‘Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria’, Sexual and Relationship Therapy, 29(2), pp. 154–214. doi: 10.1080/14681994.2014.883353.