WPATH Standards of Care Version 8

In September 2022, the World Professional Association for Transgender Health, or WPATH for short, published the eighth version of its Standards of Care. This guideline is used worldwide by doctors, insurers and governments as a benchmark for transgender healthcare. The previous version dated from 2012.

What was new

For the first time, Version 8 included a separate chapter on adolescents. It states that medical treatment should be preceded by a comprehensive assessment that also takes mental health issues and the young person’s development into account. New chapters were added as well, including one on non-binary people.

The age limits that were removed

A draft version included minimum ages for hormones and surgery in minors. Shortly after publication, a correction was issued in which those ages had been removed. The final text no longer specifies a lower age limit; the assessment is left to the treatment team. This led to widespread criticism, because no clear explanation was given of the scientific grounds on which the limits had been removed.

The criticism

As part of the research for the British Cass Review, the University of York assessed the quality of international guidelines. The WPATH guideline received a low score for the rigour of its supporting evidence. The researchers also found that guidelines in this field frequently cite one another, creating a stronger impression of broad agreement than the underlying evidence warrants. More about the objections can be found on the page about the criticism of the WPATH guideline.

What the guideline itself says about the evidence

The chapter on adolescents acknowledges that the number of studies on treatment outcomes in young people is small and that a systematic literature review was therefore not possible. The recommendations are based to a significant extent on the consensus among the experts who contributed to the guideline. The first Standards of Care were published in 1979; at the time, WPATH was still called the Harry Benjamin International Gender Dysphoria Association. In the Netherlands, there is also a separate quality standard for transgender healthcare.

How the guideline was developed

More than one hundred experts contributed to Version 8, divided across eighteen chapters. Each recommendation was submitted to all the authors and approved if at least three-quarters agreed with it. For some topics, WPATH commissioned literature reviews from Johns Hopkins University. The guideline runs to more than 250 pages and covers not only hormones and surgery, but also topics such as voice therapy, fertility, healthcare in prisons and care for older people.

What became known later

In 2024, internal WPATH documents were made public in a US court case concerning a ban on gender-affirming care for minors. According to reports in, among others, The New York Times, they showed that staff members of the US Deputy Secretary of Health had urged the removal of the minimum ages, fearing that lawmakers would use them to ban care. It also emerged that WPATH had imposed conditions on the publication of the literature reviews it had commissioned. WPATH maintains that the guideline is based on scientific grounds. Nevertheless, the documents damaged confidence in how the guideline was developed, including among some practitioners. Earlier that year, internal messages from WPATH members had already been leaked—the so-called WPATH Files; transtijd.nl describes what they contained and why the leak changed the debate in the article about the 2024 WPATH Files. In 2026, a section chair of the US professional association ACOG resigned following criticism of the WPATH guidelines; see the news report about it.

Significance

Version 8 is the guideline referenced by doctors, insurers and judges worldwide. At the same time, it appeared as Finland, Sweden and England were taking a different course based on their own literature reviews; see the 2022 Swedish guidelines. Since then, two approaches have existed side by side: that of professional associations, which regard the treatment as accepted care, and that of a growing number of national health authorities, which consider it insufficiently evidence-based for minors. The first version was published in 1979; see the first Standards of Care.