The reproduction of knowledge hierarchies in transgender medicine: Professional, lay, and global expertise in clinical practice guidelines

The process for developing clinical practice guidelines in medicine has changed dramatically over time. Previously, small groups of clinicians crafted clinical practice guidelines based on their professional expertise, but guideline developers must increasingly consider patients’ lay expertise, global expertise, and principles of evidence-based medicine. This article analyzes how the World Professional Association for Transgender Health grappled with diverse forms of expertise and evidence-based medicine in the process of creating its “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8” (hereafter, SOC-8), a prominent set of clinical practice guidelines in transgender medicine. Analysis is based on 83 interviews with clinicians, patients, and activists in the U.S. and Thailand between 2019 and 2021, as well as observation of transgender health conferences and content analysis of written materials. I find that despite the ostensible goal of incorporating more diverse expertise in this version of the guidelines, the SOC-8 ultimately reproduced traditional knowledge hierarchies in science and medicine in which the lay expertise of transgender and gender non-conforming patients and expertise from the Global South remain marginalized. I attribute this re-marginalization to the regulatory objectivity enacted in the SOC-8 revision process, which re-legitimized professional expertise, established no formal infrastructure for ensuring the equal participation of Global South stakeholders, and permitted limited inclusion of lay expertise from transgender and gender non-conforming people with relatively high levels of privilege (according to race, education, and other social statuses). These findings have implications for future research on knowledge hierarchies in science and medicine and the creation of clinical practice guidelines.