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Standards of Care


The World Professional Association of Transgender Health (WPATH) is a 501(c)(3) non-profit, interdisciplinary professional and educational organization focused on transgender health. Their members are engaged in clinical and academic research to develop evidence based medicine and work towards the safe and effective treatment for transgender, non-binary, intersex, and gender-nonconforming individuals internationally.

The Standards of Care (SOC) is the guiding document for transgender related healthcare worldwide developed by WPATH and its members. This document has been in existence since 1979. As medicine is always evolving, the WPATH members meet to work on updates to the document based on evidence based science. The SOC version 8 is the current revision.

As the SOC is a substantial document, I am going to extract key lines below and you are obviously free to go to those sections if you wish to read deeper on that context. Many conclusive statements are noted with the appropriate study and the last ~100 pages of the document are a vast collection of evidence based references. Note, I am still in the processing of consuming this document and will add more references as I read further.

Link to the Standards of Care:

Acronyms used below:
TGD – Transgender and Gender Diverse
GAMST – gender-affirming medical and surgical treatment
GnRH – gonadotropin releasing hormone

SectionPageQuoted Statement
Introduction8The SOC-8 supports the role of informed decision-making and the value of harm reduction approaches.
Introduction9Worldwide, TGD people are sometime forced by family members or religious communities to undergo conversion therapy. WPATH strongly recommends against any use of reparative or con- version therapy (see statements 6.5 and 18.10).
2192.1- We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.
219Provide health care (or refer to knowledgeable colleagues) that affirms gender identities and expressions, including health
care that reduces the distress associated with gender dysphoria (if this is present)
219Reject approaches that have the goal or effect of conversion and avoid providing any direct or indirect support for such
approaches or services.
219Match the treatment approach to the specific needs of clients, particularly their goals for gender identity and expression
219It should be recognized gender diversity is common to all human beings and is not pathological.
220Gender-affirming interventions are based on decades of clinical experience and research; there- fore, they are not considered experimental, cos- metic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria
222Finally, sexual health outcomes for TGD people are poor. HIV prevalence for transgender women reporting to clinical organizations in metropolitan areas is approximately 19% worldwide, which is 49 times higher than the background prevalence rate in the general population
222Gender identity change efforts (gender repar- ative or gender conversion programs aimed at making the person cisgender) are widespread, cause harm to TGD people and are consid- ered unethical
328Summary of reported proportions of TGD people in the general population
Health systems-based studies: 0.02–0.1%
survey-based studies of adults: 0.3–0.5% (transgender), 0.3–4.5% (all tgd)
survey-based studies of children and adolescents: 1.2–2.7% (transgender), 2.5–8.4% (all tgd)
5345.6- We suggest health care professionals assessing transgender and gender diverse people seeking gonadectomy consider a minimum of 6 months of hormone therapy as appropriate to the tgd person’s gender goals before the tgd person undergoes irreversible surgical intervention (unless hormones are not clinically indicated for the individual).
537While marked and sustained gender incongru- ence should be present, it is not necessary for TGD people to experience severe levels of distress regard- ing their gender identity to access gender- affirming treatments. In fact, access to gender-affirming treat- ment can act as a prophylactic measure to prevent distress 
538-39Recent longitudinal studies suggest mental health symptoms experienced by TGD people tend to improve following GAMSTs
539It is vital gender-affirming care is not impeded unless, in some extremely rare cases, there is robust evi- dence that doing so is necessary to prevent significant decompensation with a risk of harm to self or others. In those cases, it is also important to consider the risks delaying GAMSTs poses to a TGD person’s mental and physical health
542Previous versions of the SOC guidelines have required TGD individuals to be assessed for GAMSTs by two qualified HCPs. It was believed having two independent opinions was best prac- tice as it ensured safety for both TGD people and HCPs.
However, the limited research in the area indi- cates two opinions are largely unnecessary.
Consequently, if written documentation or a letter is required to recommend gender-affirming medical and surgical treatment (GAMST), TGD people seeking treatments including hormones, and genital, chest, facial and other gender-affirming surgeries require a single written opinion/signature from an HCP competent to independently assess and diagnose
543The decision to detransition appears to be rare (Defreyne, Motmans et al., 2017; Hadje-Moussa et al., 2019; Wiepjes et al., 2018). Estimates of the number of people who detran- sition due to a change in identity are likely to be overinflated due to research blending differ- ent cohorts (Expósito-Campos, 2021).
A recent study found the vast majority of TGD people who opted to detransition did so due to external factors, such as stigma and lack of social support and not because of changes in gender identity (Turban, King et al., 2021).
645Studies from high school samples indicate much higher rates than earlier thought, with reports of up to 1.2% of partici- pants identifying as transgender (Clark et al., 2014) and up to 2.7% or more (e.g., 7–9%) expe- riencing some level of self-reported gender diver- sity (Eisenberg et al., 2017; Kidd et al., 2021; Wang et al., 2020).
647Dutch longitudinal clinical follow-up studies of adolescents with childhood gender dysphoria who received puberty suppression, gender-affirming hormones, or both, found that none of the youth in adulthood regretted the decisions they had taken in adolescence (Cohen-Kettenis & van Goozen, 1997; de Vries et al., 2014).
647One researcher attempted to study and describe a spe- cific form of later-presenting gender diversity expe- rience (Littman, 2018). However, the findings of the study must be considered within the context of significant methodological challenges, including 1) the study surveyed parents and not youth perspectives; and 2) recruitment included parents from community settings in which treatments for gender dysphoria are viewed with scepticism and are criticized. However, these findings have not been rep- licated.
649In a large non-probability sample of transgender-identified adults, Turban et al. (2022) found those who reported access to gender-affirming hormones in adolescence had lower odds of past-year suicidality compared with transgender people accessing gender- affirming hormones in adulthood.
649Two Dutch studies report low rates of adoles- cents (1.9% and 3.5%) choosing to stop puberty suppression (Brik et al., 2019; Wiepjes et al., 2018).
6506.4- We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent.
6506.5- We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
650The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):
6.12- We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
6.12.a- the adolescent meets the diagnostic criteria of gender incongruence as per the ICd-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICd, other taxonomies may be used although efforts should be undertaken to utilize the latest ICd as soon as practicable.
6.12.b- the experience of gender diversity/incongruence is marked and sustained over time.
6.12.c- the adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment. 6.12.d- the adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
6.12.e- the adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development. 6.12.f- the adolescent has reached tanner stage 2 of puberty for pubertal suppression to be initiated.
6.12.g- the adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.
654Russell et al. (2018) found mental health improvement increases with more acceptance and affirmation across more settings (e.g., home, school, work, and friends). Rejection by family, peers, and school staff (e.g., intentionally using the name and pronoun the youth does not identify with, not acknowledging affirmed gender identity, bullying, harassment, verbal and physical abuse, poor relationships, rejection for being TGD, evic- tion) was strongly linked to negative outcomes, such as anxiety, depression, suicidal ideation, sui- cide attempts, and substance use
655Conversion/reparative therapy has been linked to increased anxiety, depression, suicidal ideation, suicide attempts, and health care avoidance
660Importantly, gender histories may be unknown to parent(s)/ caregiver(s) because gender may be internal expe- rience for youth, not known by others unless it is discussed. For this reason, an adolescent’s report of their gender history and experience is
central to the assessment process.
662Therefore, the level of reversibility of a gender-affirming medical intervention should be considered along with the sustained duration of a young person’s experience of gender incon- gruence when initiating treatment.
However, in this age group of younger adolescents, several years is not always practical nor necessary given the premise of the treatment as a means to buy time while avoiding distress from irreversible pubertal changes. For youth who have experienced a shorter 
663Importantly, findings from studies of gender incongruent pubertal/adolescent cohorts, in which participants who have under- gone comprehensive gender evaluation over time, have shown persistent gender incongruence and gender-related need and have received refer- rals for medical gender care, suggest low levels of regret regarding gender-related medical care decisions (de Vries et al., 2014; Wiepjes et al., 2018). Critically, these findings of low regret can only currently be applied to youth who have demonstrated sustained gender incongruence and gender-related needs over time as estab- lished through a comprehensive and iterative assessment 
664-65Of note, many transgender adolescents are well-functioning and experience few if any mental health concerns. For example, socially transi- tioned pubertal adolescents who receive medical gender-affirming treatment at specialized gender clinics may experience mental health outcomes equivalent to those of their cisgender peers
666The use of puberty-blocking medications, such as GnRH analogues, is not recommended until children have achieved a minimum of Tanner stage 2 of puberty because the experience of physical puberty may be critical for further gender identity development for some TGD ado- lescents (Steensma et al., 2011). Therefore, puberty blockers should not be implemented in prepubertal gender diverse youth (Waal & Cohen-Kettenis, 2006).
668Chest masculinization surgery can be considered in minors when clinically and developmentally appropriate as determined by a multidisciplinary team experienced in adolescent and gender development.
668GAHT, specifically estrogen, can help with development of breast tissue, and it is recommended youth have a minimum of 12 months of hormone therapy, or longer as is surgically indicated, prior to breast augmentation unless hormone therapy is not clinically indicated or is medically contraindicated.
775Not all gender diverse children or their families need input from MHPs as gender diversity is not a mental health disorder (Pediatric Endocrine Society, 2020; Telfer et al., 2018).
778Thus, when considering a social transition, we suggest parents/caregivers and HCPs pay particular attention to children who consistently and often persistently articulate a gender identity that does not match the sex designated at birth.
1313113.7- We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.