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

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]

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]

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]}

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]

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]

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]

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]

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

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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.

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 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.

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

• Transgender health care
• List of transgender-related topics

• WPATH Standards of Care Archived August 14, 2015, at the Wayback Machine
• Health Law Standards of Care for Transsexualism