Updated Standards Provide Crucial Guidance for Health of Transgender and Gender Diverse People

Endocrinologists and other physicians gained important guidance in September 2022, as the World Professional Association for Transgender Health (WPATH) released version eight of its Standards of Care for the Health of Transgender and Gender Diverse People—the first update in 10 years. The evidence-based standards are crucial in a field often beset by misinformation and a lack of concrete data, particularly in gender-affirming hormone therapies and management of care, says Joshua Safer, MD, Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery (CTMS), who co-authored the new WPATH guidelines.

“The field of transgender medicine has shifted significantly over the past decade, and the revised WPATH standards are notable for their recommendations based on the latest scientific evidence and literature,” says Dr. Safer, an international authority in transgender health. “These new standards are designed to help endocrinologists and physicians in a wide range of specialties who treat transgender individuals to deliver the most informed care possible.”

To develop the eighth version of the Standards of Care, known as SOC-8, subcommittees of international professionals and stakeholders made recommendation statements based on data derived from independent systematic literature reviews and expert opinions. These recommendations were vetted by the larger group of about 100 writing committee members, based on the available evidence on interventions, a discussion of risk and harm, as well as the feasibility and acceptability within different contexts and country settings. As a result, 18 chapters were developed, on subjects including primary care, reproductive health, mental health, and the specific needs of adolescents and children.

The updated guidance includes 21 recommendations on hormonal therapy. Among the more significant additions was explanatory text relating to the addition of progestogens to gender-affirming therapeutic regimens. While some practitioners are known to prescribe progestogens (including micronized progesterone) under the impression it may improve breast and/or areolar development, the new WPATH report (published in the International Journal of Transgender Health) was unable to uncover any quality evidence supporting a benefit of progestogen therapy for transgender women. What its authors did find, however, was potential harm of some progestogens in the setting of multiyear exposure. Indeed, several studies have reported an association between progestogen use and increased thromboembolism risk and decreased HDL levels.

“We didn’t feel we had enough scientific evidence to make a specific recommendation either against or in favor of the use of progestogens for gender-affirming therapy,” explains Dr. Safer, who was also inaugural president of the United States Professional Association for Transgender Health. “At the same time, we didn’t want to ignore this important area, given the fact progestogen use is widely promoted on the internet, so we summarized in our report the full range of findings. It’s especially important that endocrinologists be aware of the potentially harmful effects of progestogens.”

Another timely standard of care section in which Dr. Safer played a large role for WPATH, care for intersex people, was more definitive in its recommendations. The report suggested that health care professionals counsel parents of intersex children to delay gender-affirming genital surgery, gonadal surgery, or both, when feasible, as a way to optimize the child’s ability to participate in the decision based on informed consent.

“This is the first time, I think, that any major medical organization has put this down on paper as a recommendation,” Dr. Safer says. “One of the biggest changes over the past decade has been recognition by the medical establishment that gender identity biology is part of reproductive biology in the brain. That is, knowing what sex you are is part of reproductive biology.” Accordingly, WPATH noted that genital surgery in young children may not be aligned with the person’s gender identity and future needs. The Standards of Care points out, however, that some anatomic variations, such as obstruction of urinary flow or exposure of pelvic organs, pose a risk to the child’s physical health and must be addressed promptly.

A conservative approach was applied by WPATH to care for transgender and gender diverse (TGD) children. For TGD adolescents, the standards recommend that health care professionals begin hormone suppression only after the patient first exhibits physical changes of puberty. In general, the goal of GnRHa administration in TGD adolescents is to defer further development of the secondary sex characteristics in order to provide time to consider gender-affirming treatment options in a methodical way.

“Although much work remains to be done, the new guidance from WPATH represents a major step forward in using evidence to guide the gender-affirming health care framework for TGD people,” Dr. Safer says.