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Standards of Care for the Health of Transgender and Gender Diverse People

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The Standards of Care for the Health of Transgender and Gender Diverse People (SOC) is an international clinical protocol by the World Professional Association for Transgender Health (WPATH) outlining the recommended assessment and treatment for transgender and gender-diverse individuals across the lifespan including social, hormonal, or surgical transition.[1] It often influences clinicians' decisions regarding patients' treatment. While other standards, protocols, and guidelines exist – especially outside the United States – the WPATH SOC is the most widespread protocol used by professionals working with transgender or gender-variant people.[2][3][4]

Version 8 of the WPATH SOC, the latest version, was released online on September 15, 2022.[1][5]

History and development

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Prior to the advent of the first SOC, there was no semblance of consensus on psychiatric, psychological, medical, and surgical requirements or procedures. Before the 1960s, few countries offered safe, legal medical options and many criminalized cross-gender behaviors or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment."

The WPATH SOC are periodically updated and revised. The eighth and latest version was released on September 15, 2022. Previous versions were released in 1979 (1st),[6] 1980 (2nd),[7] 1981 (3rd),[8][9] 1990 (4th),[10] 1998 (5th),[11] 2001 (6th),[12][13] and 2012 (7th).[3]

Versions 1 to 4

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The first four versions of the Standards of Care were titled Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons.[6][7][8][9][10] The first version was released in 1979 and revisions were made in 1980, 1981, and 1990.[6][7][8][9][10] These revisions were relatively minor, with the text staying mostly the same between versions.[14][15][16] These versions of the SOC followed the gatekeeping model laid out by Harry Benjamin, where clinicians set strict eligibility requirements, requiring evaluations from separate mental health professionals and compulsory psychotherapy.[15][17][16]

The first four versions of the Standards of Care were published as standalone documents by the Harry Benjamin International Gender Dysphoria Association.[6][7][8][9][10] However, the third version was also published as a 1985 reprint in the journal Archives of Sexual Behavior.[9][non-primary sources needed]

Version 5

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In the 1990's, WPATH was struggling to operate due to criticisms of their SOC in the trans community such as the requirement of the real life test, [18] where patients had to socially transition for up to a year prior to hormones. These critiques developed into a trans-led Advocacy and Liaison committee, marking the first time trans people were officially and actively consulted regarding their treatment.[19] The 5th version,[11] published in 1998, was titled the "Standards of Care for Gender Identity Disorders" to be consistent with the DSM-III. It recommended but did not require psychotherapy and stated that while GID was a mental disorder, that was not a license for stigma.[15]

Version 6

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The sixth version was published in 2001 and offered more flexibility and individualized care but continued to use the phrase "gender identity disorder". At the same time transgender people increasingly complained of having to "jump through hoops".[15] SOC 6 also did not include significant changes to the tasks mental health professionals were required to take or in the general recommendations for content of the letters of readiness.[20] An important change in the eligibility criteria for GAH allowed providers to prescribe hormones even if patients had not undergone the "Real Life Test" or psychotherapy if it was for harm reduction purposes.[20] A notable change in version six separated the eligibility and readiness criteria for top and bottom surgery allowing some patients,[21][full citation needed] particularly individuals assigned female at birth, to receive a mastectomy.[20][22]

Version 7

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The seventh version, titled "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People", was published in 2012 both in the International Journal of Transgenderism and as a standalone document. Included in the guidelines are sections on purpose and use of the WPATH SOC, the global applicability of the WPATH SOC, the difference between gender nonconformity and gender dysphoria, epidemiology, treatment of children, adolescents and adults, mental health, hormone replacement therapy (masculinizing or feminizing; HRT), reproductive health, voice and communication therapy, gender-affirming surgery, lifelong preventive and primary care, applicability of the WPATH SOC to people living in institutional environments, and applicability of the WPATH SOC to people with disorders of sex development.

The seventh version also includes acknowledgements of the ever-evolving language used to describe and treat transsexual, transgender, and gender non-conforming individuals. There is an emphasis placed on the idea that identifying with these labels does not inherently qualify someone as disordered, and that treatment should be focused on the alleviation of any suffering caused by gender dysphoria. They make a stance against the "deprivation of civil and human rights" on the grounds of someone's gender identity. This version, much like its predecessor requires referrals for surgical procedures based on set criteria, but notes the importance of informed consent and listening to the wishes of the patient.[3]

The seventh version includes a section distinguishing between cases of gender dysphoria and non-conformity for children and adolescents, as well as recommended treatment paths for each.[3]

A systematic review into international guidelines for management of gender dysphoria and gender incongruence in children and adolescents published as part of the Cass Review in 2024 stated WPATH SOC 7 lacked "developmental rigour and transparency".[23]

Version 8

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The eighth version, titled "Standards of Care for the Health of Transgender and Gender Diverse People", was published in 2022. It gives recommendations for health professionals in eighteen chapters.[1] The guidelines were developed by a multidisciplinary committee of experts, building on previous versions and using the Delphi method.[5]

Version 8 is the first one to include a chapter on adolescent care separate from that on the care of children.[24] This version of the protocol gives no specific age limits for treatments, emphasizing the need to decide individually for each patient.[25] It was criticized for suggesting that young people may come to believe they are transgender through social influence.[24]

An earlier draft would have required several years of transgender identity before an adolescent could begin treatment. After criticism from transgender advocates, as well as from staff of Assistant Secretary for Health of the US Department of Health and Human Services (HHS), this provision was removed in the final release. Despite the criticism, transgender youths wishing to be treated are still required to undergo a "comprehensive diagnostic assessment".[26][27] In a statement by a spokesperson for the HHS, they explained that Assistant Secretary Levine "shared her view with her staff that publishing the proposed lower ages for gender transition surgeries was not supported by science or research, and could lead to an onslaught of attacks on the transgender community."[28] In July 2024, the Biden administration said they opposed gender-affirming surgery for transgender minors, but also said they would continue to support gender-affirming care for minors and would continue to oppose bans on such treatments, including continuing to oppose bans on surgeries.[29][27][30] In August 2024, the Republican chairwoman Lisa McClain of the U.S. Congress Subcommittee on Health Care and Financial Services announced that it started an investigation and requested documents and information from the HHS related to its interactions with WPATH.[31]

The guidelines became a focus of controversy during the debate over the Scottish government's Gender Recognition Reform Bill in 2022. Opponents of the bill highlighted the chapter on eunuchs, which proposes eunuch be considered a gender identity, and criticised NHS Scotland's association with WPATH.[32]

NHS England commissioned the Cass Review to create guidelines for transgender people in England. A systematic review into international guidelines published as part of the review was published in 2024 and stated that WPATH SOC 8 lacked "developmental rigour and transparency".[23] NHS England in March 2024 updated their guidelines and stated that for children and adolescents they do not follow WPATH 8.[33]

Populations

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Issues specific to certain demographics, including adults, children, and adolescents, are described in chapters 5–11 of version 8.

Adults

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Adolescents

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In a departure from previous versions, Version 8 draws a conceptual distinction between Adolescents and Children with separate chapters.

Continued care and careful assessment of cognitive maturity by qualified mental health professionals is recommended. In contrast to previous versions, there are no absolute requirements for duration of assessments or age to access gender-affirming treatments; rather, individual psychosocial and physical development should be taken into account.

Additionally, Chapter 12 and 13 and Appendix D contain further recommendations regarding hormone therapy and surgical treatments in adolescents.

Children

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Pertaining to prepubescent children only, chapter 7 makes recommendations regarding the support of children and their families throughout gender exploration and potential social transitions.

Non-binary

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Non-binary individuals are included for the first time in chapter 8. The guidelines recommend that medical treatment and social support be made available to non-binary people in individualized combinations, for example providing medical interventions without social transition or gender-affirming surgery without hormone therapy. The chapter additionally notes unique experiences of discrimination, minority stress, and difficulty accessing gender-affirming medical treatment among non-binary people, which healthcare providers should take into consideration.

Treatments

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Recommendations for treatments, including medical and social aspects of gender transition as well as mental health, as are given in Chapters 12–18.

See also

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References

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  1. ^ a b c Coleman, E.; et al. (August 19, 2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (Suppl 1): S1–S259. doi:10.1080/26895269.2022.2100644. ISSN 2689-5269. PMC 9553112. PMID 36238954.
  2. ^ Britt Colebunders; et al. (2015). "New Criteria for Sex Reassignment Surgery: WPATH Standards of Care, Version 7, Revisited". International Journal of Transgenderism. 16 (4): 222–233. doi:10.1080/15532739.2015.1081086. S2CID 74097076.
  3. ^ a b c d Coleman, Eli; et al. (2012). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7" (PDF). International Journal of Transgenderism. 13 (4). World Professional Association for Transgender Health: 165–232. doi:10.1080/15532739.2011.700873. ISSN 1553-2739. Archived from the original (PDF) on March 27, 2018. Retrieved May 9, 2018.
  4. ^ Grinberg, Emanuella (June 20, 2018). "What is medically necessary treatment for gender-affirming health care?". CNN. Archived from the original on June 27, 2023. Retrieved July 6, 2018.
  5. ^ a b World Professional Association for Transgender Health (September 15, 2022). "World Professional Association for Transgender Health (WPATH) Releases the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8" (PDF) (Press release). Archived (PDF) from the original on September 20, 2022. Retrieved September 18, 2022.
  6. ^ a b c d Walker, P. A.; Berger, J. C.; Green, R.; Laub, D. R.; Reynolds, C. L.; Wollman, L. (February 13, 1979), Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons (1 ed.), Palo Alto, California: The Harry Benjamin International Gender Dysphoria Association, Inc.
  7. ^ a b c d Walker, P. A.; Berger, J. C.; Green, R.; Laub, D. R.; Reynolds, C. L.; Wollman, L. (January 20, 1980), Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons (2 ed.), Stanford, California: The Harry Benjamin International Gender Dysphoria Association, Inc., archived from the original on September 9, 2024, retrieved May 15, 2024
  8. ^ a b c d Walker, P. A.; Berger, J. C.; Green, R.; Laub, D. R.; Reynolds, C. L.; Wollman, L. (March 9, 1981), Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons (3 ed.), San Francisco, California: The Harry Benjamin International Gender Dysphoria Association
  9. ^ a b c d e Walker, P. A.; Berger, J. C.; Green, R.; Laub, D. R.; Reynolds, C. L.; Wollman, L. (February 1985). "Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons [3rd Edition]". Archives of Sexual Behavior. 14 (1): 79–90. doi:10.1007/BF01541354. ISSN 0004-0002. PMID 3977585.
  10. ^ a b c d Walker, P. A.; Berger, J. C.; Green, R.; Laub, D. R.; Reynolds, C. L.; Wollman, L. (January 25, 1990), Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons (4 ed.), San Francisco, California: The Harry Benjamin International Gender Dysphoria Association, archived from the original on February 27, 2004, retrieved May 15, 2024{{citation}}: CS1 maint: bot: original URL status unknown (link)
  11. ^ a b Levine, S. B.; Brown, G.; Coleman, E.; Cohen-Kettenis, P.; Joris Hage, J.; Van Maasdam, J.; Petersen, M.; Pfaefflin, F.; Schaefer, L. C. (June 1998). "The Standards of Care for Gender Identity Disorders [5th Edition]". International Journal of Transgenderism. 2 (2). Archived from the original on December 5, 1998. Retrieved May 15, 2024. Consultants: Dallas Denny MA, Domineco DiCeglie MD, Wolf Eicher MD, Jamison Green, Richard Green MD, Louis Gooren MD, Donald Laub MD, Anne Lawrence MD, Walter Meyer III MD, C. Christine Wheeler Ph.D{{cite journal}}: CS1 maint: bot: original URL status unknown (link)
  12. ^ Meyer, W.; Bockting, W. O.; Cohen-Kettenis, P.; Coleman, E.; DiCeglie, D.; Devor, H.; Gooren, L.; Joris Hage, J.; Kirk, S.; Kuiper, B.; Laub, D.; Lawrence, A.; Menard, Y.; Patton, J.; Schaefer, L.; Webb, A.; Wheeler, C. C. (February 2001). "The Standards of Care for Gender Identity Disorders – Sixth Version". International Journal of Transgenderism. 5 (1). Archived from the original on July 9, 2001. Retrieved May 15, 2024.{{cite journal}}: CS1 maint: bot: original URL status unknown (link)
  13. ^ Meyer, W.; Bockting, W. O.; Cohen-Kettenis, P.; Coleman, E.; DiCeglie, D.; Devor, H.; Gooren, L.; Joris Hage, J.; Kirk, S.; Kuiper, B.; Laub, D.; Lawrence, A.; Menard, Y.; Patton, J.; Schaefer, L.; Webb, A.; Wheeler, C. C. (2001). "The Standards of Care for Gender Identity Disorders, Sixth Version" (PDF). Journal of Psychology & Human Sexuality. 13 (1): 1–30. doi:10.1300/J056v13n01_01. Archived from the original on March 17, 2024. Retrieved May 15, 2024.{{cite journal}}: CS1 maint: bot: original URL status unknown (link)
  14. ^ Cite error: The named reference Matte_2009 was invoked but never defined (see the help page).
  15. ^ a b c d Fraser, Lin (2015). "Gender Dysphoria: Definition and Evolution Through the Years". In Trombetta, Carlo; Liguori, Giovanni; Bertolotto, Michele (eds.). Management of Gender Dysphoria: A Multidisciplinary Approach. Springer Milan. pp. 19–31. doi:10.1007/978-88-470-5696-1_3. ISBN 978-88-470-5696-1.
  16. ^ a b Cite error: The named reference Riggs_2019 was invoked but never defined (see the help page).
  17. ^ Fraser, Lin; Knudson, Gail (March 1, 2017). "Past and Future Challenges Associated with Standards of Care for Gender Transitioning Clients". Psychiatric Clinics of North America. Clinical Issues and Affirmative Treatment with Transgender Clients. 40 (1): 15–27. doi:10.1016/j.psc.2016.10.012. ISSN 0193-953X. PMID 28159141.
  18. ^ Lawrence, Anne (November 4, 2001). SRS Without a One Year RLE: Still No Regrets. XVII Harry Benjamin International Symposium on Gender Dysphoria. Galveston, Texas. Archived from the original on June 23, 2018.
  19. ^ "Trans Care within and against the Medical-Industrial Complex". manifold.umn.edu.
  20. ^ a b c Amengual, Travis; Kunstman, Kaitlyn; Lloyd, R. Brett; Janssen, Aron; Wescott, Annie B. (October 20, 2022). "Readiness assessments for gender-affirming surgical treatments: A systematic scoping review of historical practices and changing ethical considerations". Frontiers in Psychiatry. 13. doi:10.3389/fpsyt.2022.1006024. ISSN 1664-0640. PMC 9630738. PMID 36339880.
  21. ^ Levine, Stephen; Althof, Stanley; Risen, Candace, eds. (2011). Handbook of Clinical Sexuality for Mental Health Professionals. New York, New York, United States of America: Taylor & Francis.
  22. ^ Meyer, Walter; Bockting, Walter O.; Cohen-Kettenis, Peggy; Coleman, Eli; Diceglie, Domenico; Devor, Holly; Gooren, Louis; Hage, J. Joris; Kirk, Sheila; Kuiper, Bram; Laub, Donald; Lawrence, Anne; Menard, Yvon; Patton, Jude; Schaefer, Leah (April 11, 2002). "The Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders, Sixth Version". Journal of Psychology & Human Sexuality. 13 (1): 1–30. doi:10.1300/j056v13n01_01. ISSN 0890-7064.
  23. ^ a b Taylor, Jo; Hall, Ruth; Heathcote, Claire; Hewitt, Catherine Elizabeth; Langton, Trilby; Fraser, Lorna (April 9, 2024). "Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1)". Archives of Disease in Childhood. 109 (Suppl 2): s65–s72. doi:10.1136/archdischild-2023-326499. ISSN 0003-9888. PMID 38594049. Archived from the original on September 9, 2024. Retrieved April 26, 2024.
  24. ^ a b Yurcaba, Jo (June 17, 2022). "Trans kids and advocates blame culture war for debate over adolescent health care". NBC News. Archived from the original on September 9, 2024. Retrieved September 23, 2022.
  25. ^ Nainggolan, Lisa (September 16, 2022). "WPATH Removes Age Limits From Transgender Treatment Guidelines". Medscape. Archived from the original on September 23, 2022. Retrieved September 23, 2022.
  26. ^ Bazelon, Emily (June 15, 2022). "The Battle Over Gender Therapy". The New York Times Magazine. Archived from the original on July 1, 2022.
  27. ^ a b Ghorayshi, Azeen (June 25, 2024). "Biden Officials Pushed to Remove Age Limits for Trans Surgery, Documents Show". The New York Times. Archived from the original on September 9, 2024. Retrieved August 8, 2024.
  28. ^ "White House says gender-affirming surgeries should be limited to adults". The Hill. July 3, 2024. Retrieved September 13, 2024.
  29. ^ Rummler, Orion (July 2, 2024). "White House says it opposes gender-affirming surgery for minors". The 19th. Retrieved October 11, 2024.
  30. ^ Migdon, Brooke (July 3, 2024). "White House comes out against gender-affirming surgeries for minors". The Hill. Archived from the original on September 1, 2024. Retrieved September 7, 2024.
  31. ^ "McClain Probes Biden Administration's Influence on Removal of Age Minimums for Gender Transition Procedures". United States House Committee on Oversight and Accountability. August 27, 2024. Retrieved September 7, 2024.
  32. ^ "NHS apologises for claiming eunuch is a gender identity". LBC. Archived from the original on September 9, 2024. Retrieved November 1, 2022.
  33. ^ "Puberty Suppressing Hormones (PSH) for children and adolescents who have gender incongruence/dysphoria [URN 1927" (PDF). NHS England- Children and young people’s gender services. March 14, 2024. Archived (PDF) from the original on April 7, 2024. Retrieved March 25, 2024.
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