Friday, April 19, 2024

The Cass Review and the WPATH SOC

The Cass Review draws some astonishing conclusions about the WPATH Standards of Care (SOC).

More or less, the basic upshot of the Cass Review's analysis is that the SOC is "based on shaky evidence".  They attempt to buttress this by applying the AGREE II framework to assess various SOC like frameworks (Taylor, Hall, Heathcote, Hewitt, Langton, & Fraser, 2024).  

After spending a few hours reviewing the AGREE II instrument (Browers, et al, 2010), it appears to me that applying it to the WPATH SOC correctly is a monumental task, and one that frankly I don't think the AGREE II framework is adequate for unless you were to apply it to each section of the SOC individually. Even there I think you would encounter a lot of problems making a complete analysis.  SOC v8 is some 260 pages of material to wade through, its predecessor is around 130 pages, IIRC. 

Further to that Taylor and colleagues (2024) complain that there is too much interplay between WPATH and many of the other guidelines in use, as if this is some kind of huge problem.  The reality is that WPATH is a cross-disciplinary organization that encourages collaboration across disciplines.  There are good reasons that, for example, the Endocrine Society Standard of Care and SOC v7 share a lot of material - it's called collaboration. 

A Bit of Context

The first version of what is now the WPATH SOC that I read was version 6 (Meyer, et al, 2001) - it was all of 22 pages in length.  I recall encountering earlier copies of the SOC in my travels, but I don't happen to have those in my possession today.  Compare that with the more recent versions, and I think you start to appreciate that in the intervening years, the SOC has grown substantially.  

The SOC in its current form is cross-disciplinary document, and it is far more of an ethical framework for working with transgender people than it is a prescriptive approach to treatment.  Although the name "Standard of Care" might lead the average person on the street to think that this document prescribes "How", when in reality is describes "What", and leaves the "How", and precise "When" of various treatments up to the client and the individual specialists who make up the treatment team working in collaboration with each other.

The Role and Purpose of the WPATH SOC

If you read the SOC v8 document properly, you will find that it is, in fact, not a document which prescribes specific treatment, or a specific course of treatment.  Instead, it makes a series of broad recommendations for how various health care professionals who work with gender diverse people should approach working with those people. 

One of the things that distinguishes the SOC from other similar documents in medicine is that we are talking about a class of treatment which is uniquely client-led.  While there is much made of being "client centred" (or "patient centred" in more medical contexts), working with transgender people is intrinsically so.  Each individual decides what steps to take, and when they are ready to take them.  Doctors don't decide what treatments, but rather work with their clients to help them actualize their individual goals. 

This differs from, for example, the treatment guidelines for something like Non-Hodgkins Lymphoma.  There, the focus is clearly on informed consent, but the treatment protocol is well established and the treatment team has a clear set of steps to execute, which they only deviate from when complications arise.

This is perhaps one of the areas where applying the AGREE framework to the SOC encounters problems.  The SOC is a set of best practice guidelines which need to be carefully tailored around each case.  The AGREE framework appears to be built around the idea that SOC type documents must be built around clear procedures with well documented evidence of efficacy.  That's easy in domains of medicine which are primarily built around "symptoms = disease, therefore we apply this model of treatment".  With transgender people, we are dealing with a situation where treatment is guided by the needs of the client, and in fact is directed by that client.

Further, while the various medical interventions like Gender Affirming Hormone Therapy (GAHT),  Gender Affirming Surgeries (GAS) all have known, fairly predictable physiological outcomes, but in context, the goal of those interventions also have significant psychological and social impacts that need to be considered.  In many, if not all cases, those psychological and social impacts are actually more significant than the physiological effects.  They are also much, much harder to assess.  

Issues With Incomplete Data

Treatment of transgender people has long suffered from inadequate and incomplete data.  This isn't particularly new.  Throughout its chapters on children and adolescents, the SOC is abundantly clear about what isn't known yet, and advising practitioners to proceed with caution.  

Again, in an area where there is a great deal of complexity, it should not be a surprise that any SOC type document would be advising caution.  This does not weaken the SOC itself in my view.  As I have previously argued, achieving "high quality" data when the population involved is small, and the practical realities make structures such as "double blind, randomly controlled trial" impossible, we have to be prepared to work with different strategies.  Expecting "perfect" here is impractical, and denying people access to treatment based on imperfect data is unethical, if not downright cruel. 

Interconnected Development

To complain that the WPATH SOC is "too connected" to other research in the topic ignores WPATH's own mandate as an interdisciplinary body.  It is nonsensical to suggest that this somehow taints other efforts.  

If the transgender community is small, the treatment community is even smaller.  I applaud WPATH's collaborative approach to treatment and design of the best practices document.  

Closing Comments

In my personal opinion, this systematic review of the various SOC documents out there ignores key realities of working with transgender people.  Frankly, it becomes increasingly clear that the team Cass assembled was given directives that amount to a "hit job" on current known best practices for working with transgender people.  


Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, for the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. CMAJ 2010;182:E839-842.

Coleman, E., Radix, A. E., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., Nieder, T. O., … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(1), S1-S259.

Meyer, W,  Bockting, W. O., Cohen-Kettenis, P., Coleman, E., Domenico, D., Devor, H. Gooren, L., Hage, J. J., Kirk, S., Kuiper, B, Laub, D., Lawrence, A., Menard, Y., Monstrey, S., Patton, J., Schaefer, L., Webb, A, Wheeler, C. C. (2001).  The Harry Benjamin International Gender Dysphoria Association's Standards of Care For Gender Identity Disorders, Sixth Version.  Retrieved April 19, 2024 from

Taylor, J., Hall, R., Heathcote, C., Hewitt, C. E., Langton, T., & Fraser, L. (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, archdischild-2023-326499-.

Taylor, J., Hall, R., Heathcote, C., Hewitt, C. E., Langton, T., & Fraser, L. (2024a). Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2). Archives of Disease in Childhood.

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The Cass Review and the WPATH SOC

The Cass Review draws some astonishing conclusions about the WPATH Standards of Care (SOC) . More or less, the basic upshot of the Cass Rev...