US transgender health guidelines leave age of treatment initiation open to clinical judgment

New clinical guidelines that will influence the care of transgender people in the US and internationally have removed recommendations on the minimum age for treatment, including hormones and surgery, and left decisions in the hands of clinicians.

The World Professional Association for Transgender Health (WPATH) released its “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8” (SOC8) on 15 September. The omission of minimum age recommendations for treatment was unexpected because they had been included in a draft version last spring.

The final SOC8 was expected to lower the minimum age for prescribing testosterone or oestrogen from 16 (in version 7) to 14 and to set minimum recommended ages of 15 for breast removal, 16 for breast augmentation and facial surgeries, 17 for hysterectomy, vaginoplasty, or removal of testicles, and 18 for phalloplasty.

The deletion of the age recommendations seemed to have happened at a late stage and after increased attention in social media on gender related surgery among adolescents.

The guidelines were due to be published on 6 September in the International Journal of Transgender Health, but WPATH’s executive board and SOC8 co-chairs sent notice that day to the association’s membership that because of “unforeseen circumstances, we have had to pause the release.” The journal’s publisher, Taylor and Francis, ultimately released both the final 260 page document, wrongly dated 6 September, and a separate “Correction” listing the final changes, mostly deletions from Chapter 6 “Adolescents.”12 Both the date and the publication of the separate “Corrections” were errors, said Eli Coleman, SOC8 co-chair and director of the Institute for Sexual and Gender Health at the University of Minnesota. “As the first author I did not authorise that [correction] to be published.”

The final guidelines come after a multiyear process involving several multidisciplinary committees divided into chapter areas, including new chapters dedicated to children, adolescents, non-binary people, education, and eunuchs. A chapter on ethics appeared in the draft but was removed.

The combined group of 119 committee members, including medical professionals, researchers, and community stakeholders, used the Delphi method to approve all wording, requiring agreement from at least 75% of members. Draft guidelines were posted for public comment in December 2021. The New York Times reported on the age recommendations in June.3

Since then, the age at which medical treatment is initiated, especially surgery, has been the subject of viral social media posts, some of which have targeted doctors and institutions by name. Coleman told The BMJ, “This whole controversy over treatment of youth was certainly heating up, and we got feedback from different groups who are still worried about anything that would hurt providing access to transgender youth, so we went back and really took a strong look at this last draft and we made some final decisions to make a few of these revisions.”

E Kale Edmiston, an assistant professor of psychiatry at the University of Pittsburgh and member of the SOC8 committee on adult care, said in a protected tweet that the final changes were the result of a “concerted effort on the part of a group of trans authors on the SOC8” to eliminate the “arbitrary age requirements.”

The SOC8 noted that the creation of a chapter on adolescents was due in part to the “exponential growth in adolescent referral rates.” Health system based studies previously showed referral rates under 0.1%, while newer surveys measuring “transgender” identity find prevalence of 1.2% to 2.7% among children and adolescents and “gender diverse” identities as high as 9%.

WPATH also noted that natal female adolescents were seeking gender care at twice to seven times the rate of natal males. Included in the guideline is the recommendation that care providers “undertake a comprehensive biopsychosocial assessment of adolescents” who seek medical transition and “involve relevant disciplines, including mental health and medical professionals,” as well as parents, “unless their involvement is determined to be harmful.”

The authors assert that the quality and quantity of the evidence on effectiveness of treatments in adolescents renders a systematic review “not possible” but at the same time that the evidence “indicates a general improvement in the lives of transgender adolescents” who receive medical treatment.

Erica Anderson, a California based clinical psychologist and a former WPATH board member, told The BMJ that the guidelines come at a time when in some countries there is “a pause in the widespread offering of medical intervention to a large number of young people.”

Sweden’s National Board of Health and Welfare, for example, reviewed the evidence and determined earlier this year that the “risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits” and should be offered “only in exceptional cases.”4 In June 2020 Finland’s Council for Choices in Health Care issued guidelines that called for psychosocial support as the first line treatment, hormonal treatment on a “case-by-case basis after careful consideration,” and no surgical treatment for minors.5 Medical societies in France, Australia, and New Zealand have issued similarly cautious statements in the past two years.67 In the UK the interim report of a national review into services for young people with gender identity issues concluded that “fundamental reform” was needed.8 This report also highlighted major gaps in the research on outcomes of treatment. “Evidence on the appropriate management of children and young people with gender incongruence and dysphoria is inconclusive both nationally and internationally,” it said.

Anderson said, “It’s important that we take our time to do a proper evaluation of every young person. We don’t have lab tests that reveal if someone is trans nor not, and we don’t have the power to prove who’s going to continue in their gender identity and who’s going to desist, and we have growing number of self-reported transitions that were very rapid—in my opinion, too rapid—getting on hormones right away, getting gender affirming surgery, and then shortly thereafter regretting it all.”