January 16, 2022

WPATH SOC8 Draft Guideline

SEGM critiques "Standards of Care" 8 for its lack of methodological rigor

The Society for Evidence-Based Gender Medicine (SEGM) welcomes WPATH SOC8’s acknowledgement of the profound shift in the incidence of gender dysphoria/gender incongruence and its presentation among youth, and the acknowledgement of the risk of inappropriate medical transition of youth. We also commend the increased focus on psychotherapy assessments, since gender incongruence in youth can arise from multiple causes and may have multiple paths to resolution.  

At the same time, we are disappointed by the significant methodological limitations in the draft SOC8 guideline. These are most evident in the reporting of the guideline recommendations. The recommendation statements are not always clear and actionable. There is no strength of recommendation or certainty of evidence attached to them. There is no justification about the balance of desirable and undesirable consequences for each of the recommendations. There is no evidence synthesis attached to each of the recommendations. Values and preferences, which shape the recommendations, are not articulated. These reporting issues will make it difficult for clinicians to follow the recommendations, or to be confident that following them will result in more good than harm for any given patient.

We are also concerned about the content accuracy in key sections affecting care for children and young people, which omits or misrepresents important information. We briefly outline our concerns with the Child, Adolescent, and Assessments sections in the attached document; however, the short timeline to comment precludes us from providing a detailed analysis of these sections, or any analysis of the remainder of the sections, many of which suffer from similar limitations. These gaps call into question the methodological rigor of the guideline development process itself, including the quality of the evidence synthesis underpinning the treatment recommendations.

Use of the term “Standards of Care” for WPATH’s treatment guideline is misleading. A standard of care is a treatment approach that all reasonable providers would use in a particular clinical situation. For example, penicillin or amoxicillin are the antibiotics of choice to treat group A strep pharyngitis and as such, this treatment is a standard of care. No such consensus exists for how to care for the growing numbers of youth with increasingly varied gender identity presentations. In fact, leading health systems and hospitals worldwide, including those that pioneered the practice of pediatric medical transition, such as the Karolinska—the home of the Nobel Prize in Medicine—have revised, or are currently revising their treatment protocols because of concerns about very low-quality evidence for the medical and surgical gender dysphoria interventions and their potential for harm.

With 2%-10% of youth self-expressing gender variant identities that make them eligible for hormonal and surgical interventions, an evidence-based treatment guideline is urgently needed. Unfortunately, the draft SOC8 does not meet this need. SEGM welcomes the opportunity for a productive dialogue with WPATH about the draft SOC8 and the process used to create it. We would be happy to assist or collaborate in a process to enable the creation of a true evidence-based practice guideline that prioritizes the long-term mental and physical health of gender-dysphoric and gender incongruent youth.