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College of psychiatry launches annual reviews to keep an eye on developments in gender dysphoria care
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is to begin annual reviews of its policy on the fast-changing and hotly contested topic of gender dysphoria.
Position statement 103 — adopted by the college in August 2021 after a two-year examination of the evidence base — is a more cautious, detailed policy than its March 2019 guidance, which claimed “good outcomes” for “reversible” puberty blockers.
That earlier policy also endorsed a contentious “gender-affirming” treatment guideline issued by the Royal Children’s Hospital (RCH) in Melbourne, home to Australia’s largest gender clinic.
The 2021 RANZCP statement —which does not endorse the RCH guideline, nor the pro-affirmative documents from the Endocrine Society or the World Professional Association for Transgender Health — highlights the “paucity” of evidence on treatment outcomes, especially with minors.
The RANZCP now advises a full exploratory assessment of patients, including co-existing mental health issues and various pathways to the distress of gender dysphoria.
Its policy warns psychiatrists that “evidence and professional opinion” is divided on whether the gender-affirmative approach should be used with children and adolescents.
In a note to members last month, the RANZCP said the 2021 gender dysphoria policy would be revised “based on [the] latest evidence, correspondence received by the college, and consultation with internal and external stakeholders”.
In November 2021, pro-affirmative health lobbies for Australia and New Zealand sent the RANZCP a joint letter expressing “deep concern” over the new dysphoria policy, and asking for a meeting with the college president, Associate Professor Vinay Lakra.
In July 2022, those gender lobbies collaborated in a journal article claiming that the college’s more cautious policy was “harmful” to transgender people and had framed “the trans experience as inherently pathological”.
The gender lobby article said the college’s position statement had been “used nefariously” including by some Republican-governed U.S. states seeking to restrict hormonal and surgical gender change for minors.
Published in The Australian and New Zealand Journal of Psychiatry, the pro-affirmative article was “sure to set tongues wagging in the college”, according to a message to members from the Australian Professional Association for Trans Health.
The gender-affirming treatment model for children and adolescents relies on endorsement by health professional societies — in practice, by small potentially biased expert groups — to promote itself as mainstream medicine and to compensate for the weakness of the evidence base, as confirmed by multiple systematic reviews of the scientific literature. These endorsements — and the risks of puberty blockers — are coming under more scrutiny.
The next update of the RANZCP’s gender dysphoria policy is expected to be finished and published by mid-2023. A review of emerging evidence had been agreed upon when the policy was adopted last year, according to terms of reference for the task assigned to a college steering group.
Those terms caution group members “that as they provide and interpret the evidence from published research, they need to be independent and impartial, and use best-quality measures rather than ideology”.
Asked if the gender-affirming critique had played a role in the decision to review the gender dysphoria position statement, the college president Dr Lakra told GCN that the policy would be revisited annually “to take into account any new and emerging evidence in this rapidly developing area”.
Meanwhile, the National Association of Practising Psychiatrists (NAPP) — a smaller, more clinically focused group than the RANZCP — has updated its psychology-before-medicine guidance following news that the world’s largest youth gender clinic, the Tavistock Gender Identity Development Service, is to close.
“In the UK, the one specialised clinic in England (the Tavistock clinic) offering an affirmation approach to management of gender dysphoria in children and adolescents will be closed and replaced by regional clinics offering a more holistic model of care,” the updated NAPP guidance says.
“The author of the report that led to this decision [paediatrician Dr Hilary Cass] raised substantial concerns about the effect of puberty blockers on developmental maturation and decision-making.”
NAPP president Dr Philip Morris said his association’s more cautious approach to youth gender dysphoria, first published in July 2020, was similar to new policies in Sweden and Finland applying much stricter controls to medical interventions and emphasising mainstream mental health care.
“The first response should not be immediate affirmation, puberty blockers or cross-sex hormones,” Dr Morris told GCN.
He said doctors had a duty to give children and adolescents presenting with what appears to be gender distress the same standard of care available for any other medical condition, carrying out a potentially time-consuming holistic assessment, exploring underlying issues and excluding competing diagnoses.
Video: Trailer for the documentary “Affirmation Generation”
Pathology or methodology?
In November 2021, the RANZCP’s president Dr Lakra was sent a joint letter of protest from the gender-affirming lobby groups, the Australian Professional Association for Trans Health, New Zealand’s Professional Association for Transgender Health Aotearoa, and ACON, the former AIDS Council of NSW.
“By framing the trans experience as inherently pathological, the position statement [103 of the RANZCP] will cause harm,” the letter said. “Language such as co-morbidity implies that being trans is a disorder.”
In line with the “minority stress” model, the letter argued that mental health problems among trans people reflected discrimination, stigma and rejection in society. The letter suggests that gender dysphoria can be caused by a health professional deciding eligibility for medical treatment to relieve gender dysphoria.
‘[G]ender dysphoria can be environmental: such as distress experienced as a result of having one's gender assumed or disrespected, or being required to go through harmful medical gatekeeping in order to access gender-affirming care.”
Complaining of psychiatry’s alleged history of “pathologising” trans people, the letter said the function of the profession should be limited to helping trans (or non-trans) patients with psychiatric distress.
“[Psychiatry] does not have a role in the care of trans people simply because of their gender experience, or desire for medical gender affirmation [by hormonal or surgical intervention].”
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No ideology, please
The RANZCP terms of reference urging policy reviewers to eschew ideology cite a British journal article which analyses the “depathologising” narrative of trans rights advocates and its implications for psychiatry.
(In psychiatry’s diagnostic manual, the DSM, “gender identity disorder” became the distressful non-disorder “gender dysphoria” in 2013, while today the World Health Organization’s distress-free term “gender incongruence” is increasingly common usage.)
“There is a lack of consensus demonstrated as to the exact nature of the condition [of gender dysphoria],” said the October 2021 article published in the U.K. Royal College of Psychiatry’s journal BJPsych Bulletin.
“Questions remain for psychiatrists regarding whether gender dysphoria is a normal variation of gender expression, a social construct, a medical disease or a mental illness. If merely a natural variation, it becomes difficult to identify the purpose of or justification for medical intervention,” the article said.
“Historically, a diagnosis of gender dysphoria was required before medical intervention; this is a part of standard gatekeeping that is now being criticised as a ‘barrier’ instead of regular safe medical practice.
“Now, a self-declaration of being ‘trans’ appears to be indication enough for a patient to expect their doctor to provide a range of complex medical treatments, with no evidence of dysphoria being required.
“If one's ‘internal sense of being a man or a woman’ no longer refers to a ‘man’ or ‘woman’ as defined by biological sex, then the definition of gender identity risks becoming circular.
“Within current debates, if gender identity becomes uncoupled from both biological sex and gendered socialisation, it develops an intangible soul-like quality or ‘essence’. As a pure subjective experience, it may be overwhelming and powerful, but is also unverifiable and unfalsifiable.
“[The Royal College of Psychiatry’s 2018] position statement acknowledges [the reported] elevated rates of mental illness within the transgender population, but appears to attribute them primarily to hostile external responses to those not adhering to gender norms (or sex-specific stereotypes).
“A deeper analysis of mental illness and alternative gender identities is not undertaken, and common causal factors and confounders are not explored. This is worrying, as attempts to explore, formulate and treat coexisting mental illness, including that relating to childhood trauma, might then be considered tantamount to ‘conversion therapy’.
“Although mental illness is overrepresented in the trans population it is important to note that gender non-conformity itself is not a mental illness or disorder. As there is evidence that many psychiatric disorders persist despite positive affirmation and medical transition, it is puzzling why transition would come to be seen as a key goal rather than other outcomes, such as improved quality of life and reduced morbidity.
“When the phenomena related to identity disorders and the evidence base are uncertain, it might be wiser for the [psychiatric] profession to admit the uncertainties. Taking a supportive, exploratory approach with gender-questioning patients should not be considered [unethical] conversion therapy.
“Those seeking transition are a vulnerable population who suffer from high levels of suicidality, psychiatric morbidity and associated difficulties. Medical and surgical transition is sought to relieve these psychiatric symptoms,” the BJPsych Bulletin article said.
“Plausibly, there is an initial reduction in distress following transition, although no controlled trials exist. Therefore, the long-term outcome of medical and surgical transition in terms of mortality and quality of life remains unknown.
“No long-term comparative studies exist that satisfactorily demonstrate that hormonal and surgical interventions are superior to a biopsychosocial formulation with evidence-based therapy in reducing psychological distress, body dysphoria and underlying mental illness.
“It is unclear what the role of psychiatry is in the assessment and treatment of gender dysphoria, now that it is no longer considered a diagnosable mental illness, and whether there is still a place for a routine psychosocial assessment.
“It could be argued that patients should be deterred from gender intervention pathways while co-morbid mental illness is treated. Without long-term follow-up data, it is not possible to identify those who might reconcile with their sex and those who might come to deeply regret their medical and/or surgical transition.
“Moreover, it is not transparent where ultimate and legal responsibility for decision-making lies – with the patient, parents (if the patient is a child), psychologist, endocrinologist, surgeon or psychiatrist.”
Dr Morris, president of Australia’s National Association of Practising Psychologists, said he believed that the U.K. approach, following the projected 2023 closure of the Tavistock clinic, was intended to bring gender dysphoria care back within mainstream, holistic medicine.
“This requires that doctors exercise their minds in determining diagnosis and differential diagnosis, and the underlying features or influences or risk factors or conditions that cause a young person to present with gender identity questioning at that particular time,” he said.
The NAPP’s updated guidance on gender dysphoria includes commentary on the “pathologisation” debate from paediatrician Dr Hilary Cass, author of February’s interim report leading to the decision to close the Tavistock.
“Applying medical thinking to gender identity isn't required until and unless a young person needs treatment,” Dr Cass said. “The regulations are particularly tightly defined when a doctor is considering prescribing medication, and especially medication that may have some life-long effects.
“Doctors then have a professional obligation to go through a process of ensuring that it is appropriate for the health needs of the individual, which means making a positive diagnosis (what the condition is) and a differential diagnosis (what the condition isn't).
“This applies in all areas of medicine. The process of differential diagnosis is neutral in terms of outcome — it's not about preferring one diagnosis over another; it's just about getting it right.
“It isn't about trying to rule out every conceivable explanation before confirming any particular diagnosis — only about ruling out other diagnoses that might be likely for that individual, or where getting it wrong and missing another diagnosis could have serious consequences.
“Achieving this involves taking a holistic, considered approach to each individual about the possible causes of their distress and identifying the most appropriate pathway for them.”