Endocrine Society Guideline for Transgender Care

In 2017, the Endocrine Society published the guideline 'Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons' under the leadership of Wylie Hembree.

Status and purpose

In 2017, the Endocrine Society published the guideline 'Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons' under the leadership of Wylie Hembree. The guideline replaces earlier versions from 2009 and is internationally regarded as authoritative for the endocrine aspects of transgender care.

Contents

The guideline covers diagnosis, evaluation of adults and adolescents, hormone treatment (feminizing and masculinizing), monitoring, fertility counseling, and specific considerations for young people.

Criticism

The guideline has been criticized for the extent to which it follows systematic reviews. The University of York reviews underlying the Cass Review concluded that the recommendations of the Endocrine Society and WPATH are not always supported by evidence of sufficient quality.

Recommendations for young people

For young people, the guideline recommends considering puberty blockers once puberty has begun, from Tanner stage 2 onward. According to the guideline, cross-sex hormones can be started when the young person is capable of providing informed consent, which the authors say is the case for most young people around the age of sixteen. The guideline calls for assessment by a multidisciplinary team with experience in mental healthcare for young people. The authors include Dutch researchers Peggy Cohen-Kettenis and Louis Gooren; the recommendations are consistent with the Dutch Protocol.

Strength of the evidence

The guideline uses the GRADE system, which indicates the quality of the underlying evidence for each recommendation. According to the guideline itself, the recommendations concerning young people are based on evidence of low or very low quality. The two systematic reviews conducted for the guideline examined the effects of hormones on blood lipid levels and bones. No systematic review was conducted on the effect of treatment on the psychological well-being of young people. An analysis of the weak evidence base underlying the international guidelines, including the GRADE assessments, is available at wpath.nl.

Assessment by the University of York

In 2024, researchers at the University of York assessed international guidelines for gender care for young people using the AGREE II instrument. Most guidelines scored poorly on methodological rigor. The researchers also found that guidelines refer extensively to one another: those of the Endocrine Society and WPATH rely on each other, and many national guidelines adopt their recommendations. As a result, the level of agreement appears greater than the evidence warrants. More information about their global spread is available in the timeline.