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Grading of evidence

Selected recommendations in these Guidelines have been graded using adaptation of some components of the GRADE scoring system,[1] with the addition of two additional domains to describe details of the research which underlies the recommendation, as well as the population(s) in which such research was conducted. Each graded recommendation will include mention of the population(s) in which research was conducted (transgender (T), non-transgender (NT), or both (T/NT); an indication of, among all sources informing that particular recommendation, the strongest form of underlying evidence (meta-analyses, randomized trials, observational studies, expert opinion). Lastly, an overall grading of the strength of recommendation is made (strong, moderate, weak) which is based on the above critera as well as strength of the consensus recommendation as determined by expert opinion interpretation of available data.

Key recommendations are listed in bold. Some recommendations are not graded as they are based on existing recommendations from other professional organizations.

Grading of evidence

Populations in which data exists to inform a particular recommendation
At least some data in transgender populationT
No data in transgender population, but data from other populationsNT
No data (expert opinion only)X
Strongest available data to inform a particular recommendation
Randomized controlled studiesR
Observational studiesO
Consensus expert opinionC
Overall strength of recommendation, taking into consideration the above as well as expert interpretation of available data in context


  1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6.