Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

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 t...

Readiness assessments for gender-affirming surgical treatments: A systematic scoping review of historical practices and changing ethical considerations

“…Version 8 recommends that perioperative matters, such as travel requirements, presence of stable, safe housing, hygiene/healthy living, any activity restrictions, and aftercare optimization, be discussed by the surgeon prior to GAS. In terms of eligibility criteria, the authors recommend a reduced duration of GAH from 12 months (from version 7) to 6 months (in version 8) prior to pursuing GAS involving reproductive organs ( 79 ).…”

“…The practice of requiring a diagnosis continues to put mental health and other medical providers in the position of gatekeeping, continuing the vestigial historical focus on “confirming” a person’s gender identity, rather than trusting that TGD people understand their identities better than providers do. Version 8 of the SOC put a much heavier emphasis on shared decision making and informed consent, but continue to maintain the requirement of a diagnosis ( 79 ). Many insurance companies and other health care payers require the diagnosis to justify paying for GAC, but providers should continue to advocate for removing such labels as a gatekeeping mechanism for GAC.…”

“…Over time the SOC became more flexible by removing requirements for psychotherapy, narrowing requirement for the RLT to only those pursuing bottom surgery, eliminating requirements for a mental health evaluation prior to initiating GAH, and eliminating requirements for GAH prior to top surgery. Version 8 of the SOC was even more explicit about removing requirements for psychotherapy and psychometric testing prior to receiving GAC ( 79 ).…”

“…The WPATH guidelines apply a one-size-fits-all approach to an extremely heterogeneous community who have varying levels of needs based on a variety of factors including but not limited to age, socioeconomic status, race, natal sex, and geographic location ( 90 ). It should be noted, however, that the version 8 of the SOC does acknowledge that different patients may require evaluations of varying complexity based on the procedure they are requesting as well as a variety of psychosocial factors, although it remains vague about exactly what those different evaluations should entail ( 79 ). We propose that future work be directed toward three primary goals: conducting research to determine the utility of letters of readiness; to better understand factors that impact GAS outcomes; and to develop easily accessible and understandable guides to conducting readiness evaluations and writing letters.…”

“…Version 8 of the SOC go a long way toward changing the ethical focus of evaluations toward one of shared decision making and informed consent by removing the requirement of a second letter and the requirement that the letter be written by a mental health provider. This will, in theory, lower barriers to care by allowing other providers (as long as they have at least a master’s degree) to write letters for surgery ( 79 ). In practice, however, this change is likely to only affect a small portion of the patient population.…”