The Professional Association for Transgender Health Aotearoa (PATHA) is disappointed to see the number of harmful recommendations made by the NHS-commissioned Cass Review, released yesterday in England. This review ignores the consensus of major medical bodies around the world and lacks relevance in an Aotearoa context.

The Cass Review is a report into England’s approach to providing gender affirming care through a centralised gender clinic model. The 2022 interim report found this model was not fit for purpose, with wait times for the service extending into years. As a result, the clinic was closed while the NHS determined a better approach to providing this service.

The final Cass Review did not include trans or non-binary experts or clinicians experienced in providing gender affirming care in its decision-making, conclusions, or findings. Instead, a number of people involved in the review and the advisory group previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming ‘gender exploratory therapy’, which is considered a conversion practice.

It’s shocking to see such a significant inquiry into transgender health completely disregard the voices of transgender experts. It would be like reviewing women’s health with no women, or Māori health with no Māori involved.

PATHA has shown the benefit of collaborations between transgender community members and clinicians providing gender affirming care. The lived experience and knowledge of our community members and clinicians does not make them biased - it means they’re the experts in this care.

The Review commissioned a number of systematic reviews into gender affirming care by the University of York, but seems to have disregarded a significant number of studies that show the benefits of gender affirming care. In one review, 101 out of 103 studies were discarded.

PATHA welcomes further research about the health interventions that support the wellbeing and lives of trans and non-binary people, and of trans communities locally and globally. While we certainly look forward to more longitudinal research, the evidence in support of gender affirming care is clear, and we’re disappointed to see this review discard so much robust work from researchers around the world. When multiple observational studies produce similar findings, the cumulative evidence becomes compelling.

The Review’s recommendations include restricting access to both social transition and gender affirming hormone therapy, and would require the approval of a national multi-disciplinary team for any gender affirming care to be provided to anyone under 18. Restricting access to social transition is restricting gender expression, a natural part of human diversity. Requiring clinical approval for haircuts and wardrobe changes is intrusive, inappropriate, and a waste of money and time.

We’ve seen the benefits that increased access to gender affirming care have had on trans communities around Aotearoa. Barriers to care have detrimental impacts on wellbeing, and create additional work for healthcare systems already under stress. Our holistic approach, utilising multi-disciplinary teams, works well for Aotearoa.

In Aotearoa, gender affirming care is available no matter where you live, and has evolved over the last 15 years based on clinical experience, emerging evidence, and updated guidelines. Clinicians around the country, supported by specialists and multidisciplinary teams where needed, work alongside whānau to ensure best practice that is holistic, individualised, and whānau centred, with the best possible outcomes for our rangatahi.

Clinicians working in gender-affirming care welcome the increasing body of evidence about puberty blockers. This is important to help young people and their families make the best decisions about their individualised care.

PATHA is proud to support clinicians and community members working to promote the health and wellbeing of trans and non-binary people around Aotearoa. Our members have contributed to the evidence base in support of gender affirming care, and of trans wellbeing more generally, and will continue to work to improve access and the quality of care around the country.

We’ve collaborated with AusPATH and other rainbow organisations on this statement released by Equality Australia, and encourage that everyone take good care of themselves, and take time to unplug and check in with those around you. Aroha nui and kia kaha.

AusPATH/PATHA Joint Hybrid Conference

Advocating for Change, Advancing Best Practice

2 - 4 November 2023, Melbourne, Australia

Virtual Registration Still Available!

The PATHA Executive Committee are delighted to report that the joint AusPATH/PATHA conference has sold out in-person attendance! It is amazing to know so many people are interested in this event and transgender and non-binary health and wellbeing. As the conference is hybrid, virtual registration is still available. This gives you 6 months access to content.

The AusPATH/PATHA Joint Conference will offer opportunities for professional development and networking for a multidisciplinary audience, bringing together researchers, primary healthcare providers, community, specialist clinicians, general practitioners, policy experts, academics, and mental health practitioners. This conference would be of interest to anyone who works with patients, works with transgender, non-binary, or takatāpui individuals or communities, or who is interested in learning more about this incredible area of research.

There is a concession rate for those where finances may be a barrier. If there are any students, early career researchers, or community members, for whom cost is still a barrier, we urge them to contact Cassie, the hybrid co-ordinator, at cassie.withey-rila@outlook.com.

Register your place now

If you have any questions regarding the conference, please contact Cassie or the conference secretariat at conference@ashm.org.au

The Annual General Meeting for the Professional Association for Transgender Health Aotearoa (PATHA) will be held via online video call from 2-3pm on Saturday the 22nd of July, 2023.

Agenda

1. Welcome
2. Note any apologies and appoint minute taker
3. Receiving the minutes of the previous Society Meeting
   
4. President’s Report
   
5. Financial statements
6. Election of Executive Committee members
7. General business
8. Close meeting
   

PATHA members can log in to find details of how to attend the online AGM, copies of the reports, and information about nominees for the Executive Committee.

Kia ora koutou

The abstract submissions due date for the 2023 AusPATH Conference in partnership with PATHA has been extended to 11.59pm AEST 31 May. 

We would really like to see some of the amazing mahi happening in Aotearoa and pacific regions represented in the submissions. Scholarships and online options are being finalised and will be announced soon.

Find out more about and submit your abstract at: http://auspathconference.com.au/abstract-submission/

PATHA members have created new Primary Care Gender Affirming Hormone Therapy Initiation Guidelines. These guidelines were authored to help GPs and other primary care providers to start gender affirming hormone therapy for adults. Many PATHA members helped write or improve these these guidelines.

These guidelines have been endorsed by The Royal New Zealand College of General Practitioners.

The PDF can be downloaded on PATHA's guidelines webpage, and they are also hosted on the University of Otago website here.

PATHA has co-signed the Darlington Statement!

What is the Darlington Statement?

It is a joint consensus statement by Australian and Aotearoa/New Zealand intersex organisations and independent advocates, in March 2017. It sets out the priorities and calls by the intersex human rights movement in our countries, under six headings: a preamble, human rights and legal reform; health and wellbeing; peer support; allies; and education, awareness and employment.

The Professional Association for Transgender Health Aotearoa (PATHA) regards the Darlington Statement as an essential document for governments and service providers to ensure that  their legislation, policies, and practices support and respect the rights of intersex people.

Read the full statement and more about the essential nature of this work here: https://darlington.org.au/statement/

WPATH, ASIAPATH, EPATH, PATHA, and USPATH Response to NHS England in the United Kingdom (UK) Statement regarding the Interim Service Specification for the Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) by NHS England*

Following the publication of the interim report of the Cass Review of gender identity services for children and young people in England in March 2022 NHS England has now issued an interim service specification for “Phase 1” services pending establishment of new regional services in England.

See https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/

WPATH, ASIAPATH, EPATH, PATHA, and USPATH have major reservations about this interim service specification.

1. The document fails to state that gender diversity is a normal and healthy aspect of human diversity (Coleman et al., 2022), and that many transgender people experience gender incongruence from childhood or adolescence (James et al., 2016). Transgender and gender diverse (TGD) people have a human right to access the highest achievable standard of health care, including gender-affirming care (World Health Organization, (2017; Yogyakarta Principles.org., 2007).  WPATH, ASIAPATH, EPATH, PATHA, and USPATH are concerned that rather than emphasising the importance of equitable access to medically necessary support and treatment for children, adolescents and young adults experiencing gender incongruence, the service specification appears designed to place unnecessary barriers in their way. Additionally, we state that when gender affirming medical treatment is provided with a standardised multidisciplinary assessment and treatment process, thorough informed consent, and ongoing monitoring and psychosocial support, the rate of regret of gender-affirming medical treatment commenced in adolescence has been observed to be very low and the benefits of treatment in adolescence are potentially greater than the benefits of gender-affirming treatment commenced in adulthood (Coleman et al., 2022). Hence, the harms associated with obstructing or delaying access to wished-for and indicated treatment for the majority, appear greater than the risks of regret for the few (Coleman et al., 2022), when transgender and cisgender people are correctly regarded as equal.
2. The document makes assumptions about transgender children and adolescents which are outdated and untrue, which then form the basis of harmful interventions. Amongst these is the supposition that gender incongruence is transient in pre-pubertal children.  This document quotes selectively and ignores newer evidence about the persistence of gender incongruence in children (Olson et al., 2022). Many older studies regarding the stability of gender identity enlisted children who did not have gender incongruence or gender dysphoria, but rather, had culturally non-conforming gender expression. The findings of these older studies should only carefully be applied to children and young people who are presenting to gender identity clinics seeking gender-affirming treatment: it may be a different population (Temple Newhook et al., 2018). The document also makes unsupported statements about the influence of family, social, and mental health factors on the formation of gender identity. WPATH, ASIAPATH, EPATH, PATHA, and USPATH believe that children and young people can have agency and can express their gender identity, and that the best course of action is to work collaboratively with the child or young person and family to support the TGD person (Coleman et al., 2022).
3. The document highlights that there have been approximately 5000 referrals to the NHS GIDS in 2021/2022, an increase from previous years. It states that referrals are currently 8.7 young people per 100,000 population.  These figures are not put in context.  The referrals to GIDS range between age 3 and 17.  There are 10,752,647 young people aged between 3 and 17 in England and Wales, making up 18% of the total population (Office of National Statistics, 2021).  Hence, referrals to GIDS are 8.7 young people per 18,000 same age population.  This is a rate of 0.048% of this population, or fewer than 5 in 10,000 young people.  Population estimates of the proportion of people who are transgender range from 0.3% to 0.5% in adults, and 1.2% to 2.7% in adolescents (Coleman et al., 2022).  Hence, referrals to GIDS represent a very tiny fraction of the total population of young people, and only a small proportion of those who self-identify as transgender.  These referrals are likely to be made up of those young people who have the most severe gender incongruence.  WPATH, ASIAPATH, EPATH, PATHA, and USPATH strongly recommend that services should be designed that welcome these appropriate referrals, providing expedited access to expert assessment, and treatment where appropriate (Coleman et al., 2022).
4. The document underscores the expectations of the family and parent/carer around the child/young person’s gender incongruence. WPATH, ASIAPATH, EPATH, PATHA, and USPATH’s position is that while it is important for health professionals to work inclusively with the family and parent/carer to assist children and young people on their gender journey, the needs of the child/young person must be paramount (Coleman et al., 2022). Family acceptance and support is essential for wellbeing (Pariseau et al., 2019; Russell et al., 2018; Simons et al., 2013).
5. This document seems to triage treatment based on an ability of the child or young person to prove the severity of their gender dysphoria. There is a reference to “the clarity, persistence and consistency of gender incongruence…”. WPATH, ASIAPATH, EPATH, PATHA, and USPATH believe that each person has a unique gender journey. There can be many reasons why children and young people may have trouble expressing or understanding their own gender incongruence. WPATH, ASIAPATH, EPATH, PATHA, and USPATH believe that all healthcare should be patient-centered and individually tailored (Coleman et al., 2022).
6. This document discourages social transition in pre-pubertal children. This is despite recent evidence pointing to positive mental health and social well-being outcomes in children who are allowed to socially transition in supportive environments before puberty (Durwood et al., 2017; Gibson et al., 2021). The document refers to the so-called “risks of an inappropriate gender transition” but does not name these risks or provide a reference for this statement. There is a section with criteria to support social transition in adolescents; this seems to suggest that adolescents will only be supported to socially transition if they meet the criteria set by the service. This represents an unconscionable degree of medical and State intrusion into personal and family decision-making about simple everyday matters such as clothing, name, pronouns, and school arrangements. Ultimately, social transition in practice is a personal and family decision, led by the young person, and should not require medical permission.  WPATH, ASIAPATH, EPATH, PATHA, and USPATH do not support a gatekeeping approach to social transition (Coleman et al., 2022).
7. This document severely limits access to puberty suppression by only allowing treatment in the context of a formal research protocol. The eligibility criteria for enrolment in this formal research protocol are not specified, but the concern is that they will be restrictive. WPATH, ASIAPATH, EPATH, PATHA, and USPATH disagree with this approach, and emphasise the increasing evidence that access to reversible puberty blockers, and later gender-affirming hormone treatment if wished, is associated with positive mental health and social well-being in adolescents with gender incongruence, and that adolescents are satisfied with these treatments and perceive them as essential and lifesaving (Coleman et al., 2022). We are deeply concerned that the NHS is taking inappropriate approaches to evaluating the established body of evidence and is therefore drawing erroneous conclusions underestimating the effectiveness of puberty suppression.  It is ethically problematic to compel adolescents to participate in a research study to access medically necessary treatment; research participation should be voluntary and should not occur under coercive conditions and in clinical research “the safety and wellbeing of the individual prevail over the interests of science and society” (National Health Service Health Research Authority, 2022).  It is also deeply concerning that the document does not describe any process for provision of estrogen or testosterone therapies for older adolescents.
8. At several points in the document, there is an emphasis on “careful exploration” of a child or young person’s co-existing mental health, neuro-developmental and/or family or social complexities. There is also a suggestion that a “care plan should be tailored to the specific needs of the individual following careful therapeutic exploration…”  WPATH, ASIAPATH, EPATH, PATHA, and USPATH are concerned that this appears to imply that young people who have coexisting autism, other developmental differences, or mental health problems may be disqualified, or have unnecessary delay, in their access to gender-affirming treatment.  This would be inequitable, discriminatory, and misguided (Coleman et al., 2022). WPATH, ASIAPATH, EPATH, PATHA, and USPATH recommend that puberty suppression, where urgently indicated, can be commenced promptly, and proceed alongside and at the same time as any necessary diagnostic clarification of other conditions, or treatment of other conditions. Whilst careful assessment is imperative, undue delay inherent within a model of care is not a neutral option and may cause significant harm to those accessing services (Coleman et al., 2022).
9. There is an alarming statement in the summary that “the primary intervention for children and young people… is psychosocial (including psychoeducation) and psychological support and intervention.” In another section, the document goes on to state that one outcome from the screening process would be “discharge with psychoeducation…” Disturbingly, this decision might be made without speaking directly with the young person or family. Taking No 8 and 9 together, this document seems to view gender incongruence largely as a mental health disorder or a state of confusion and withholds gender-affirming treatments on this basis. WPATH, ASIAPATH, EPATH, PATHA, and USPATH call attention to the fact that this “psychotherapeutic” approach, which was used for decades before being superseded by evidence-based gender-affirming care, has not been shown to be effective (AUSPATH, 2021; Coleman et al., 2022). Indeed, the denial of gender-affirming treatment under the guise of “exploratory therapy” has caused enormous harm to the transgender and gender diverse community and is tantamount to “conversion” or “reparative” therapy under another name.
10. This document reasserts the outdated “gatekeeping model” of access to gender affirming care. There are many references within the document to patients only being able to access care and be referred to the next intervention down the line if they can meet criteria set by the service. There are clear statements that if adolescents are taking puberty suppression or gender-affirming hormones obtained elsewhere, the service will not provide any care. The purpose of this section seems to be about empowering the service to withhold treatment and health monitoring from children or young people who have obtained medication without the permission of the service. WPATH, ASIAPATH, EPATH, PATHA, and USPATH affirm the human right of self-determination in health care (World Health Organization, 2017). Moreover, such action contravenes the core aspects of the NHS Constitution (Department of Health and Social Care, 2021). Children and adolescents can contribute substantially to their health care decision making, with age-appropriate capacity to weigh the risks and benefits according to their own judgement (Amnesty International, 2020; Steinberg, 2013; Vrouenraets et al., 2021; Weithorn & Campbell, 1982). Furthermore, WPATH, ASIAPATH, EPATH, PATHA, and USPATH recommend a harm-minimisation approach, and encourages doctors to work with people who access treatment from other sources in a non-judgmental manner to help them to maximise their health status (Coleman et al., 2022).
11. The document states that general practitioners would be advised to “initiate local safeguarding protocols” if a child or young person obtains puberty blockers or hormones from another source. This recommendation, which would see families reported to child protection services, is gravely concerning.  The draft service specification makes it clear that it will be difficult to obtain prompt access to puberty suppression.  Families who are in the position of seeing their young adolescent descend into suicidal distress as they continue to experience incongruent pubertal changes, whilst being unable to access appropriate care from the NHS service, may make the difficult decision to obtain puberty suppression through non-NHS sources, as caring parents affirming their child’s identity and supporting health care according to international treatment standards.  These parents would then be at risk of being reported to child protection services, a ludicrous and dangerous situation; or a general practitioner with a better understanding of gender incongruence might be put at risk of censure for refusing to make such an inappropriate child protection referral, against the recommendations of the specialist service. WPATH, ASIAPATH, EPATH, PATHA, and USPATH believe that the appropriate interim service specification should instead be supporting GPs and families to provide the best evidence-based and compassionate care for children and young people with gender incongruence, including access to puberty suppression and gender-affirming hormones where indicated (Coleman et al., 2022; de Vries et al., 2021).

Overall, WPATH, ASIAPATH, EPATH, PATHA, and USPATH find serious flaws in this document, which sets out a plan for a service for gender diverse children and young people in England that is likely to cause enormous harm and exacerbate the higher rates of suicidality experienced by these young people in the context of ongoing pathologisation and discrimination.  WPATH, ASIAPATH, EPATH, PATHA, and USPATH urge NHS England and Wales to reconsider its approach, which is now contrary to the progress being made in many countries around the world and incongruent with statements from the World Health Organization (2017) and the Yogyakarta Principles (2007) relating to the right to the highest attainable standard of health.

*PATHA and other PATH associations thank AUSPATH for allowing the use of the content of their Statement issued on 16 November 2022 about the Interim Service Specification for the Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) by NHS England.

References

Amnesty International (2020). Amnesty International UK and Liberty joint statement on puberty blockers. https://www.amnesty.org.uk/press-releases/amnesty-international-uk-and-liberty-joint-statement-puberty-blockers

AUSPATH (2021). Australian Professional Association for Trans Health Public Statement on Gender-affirming Healthcare including for Trans Youth.  https://auspath.org.au/2021/06/26/auspath-public-statement-on-gender-affirming-healthcare-including-for-trans-youth  

Coleman, E., Radix, A. E., Bouman, W.P., Brown, G.R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F.L., Monstrey, S. J., Motmans, J., Nahata, L., ... Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(S1), S1-S260. https://doi.org/10.1080/26895269.2022.2100644

de Vries, A. L. C., Richards, C., Tishelman, A. C., Motmans, J., Hannema, S. E., Green, J., & Rosenthal, S. M. (2021). Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. International Journal of Transgender Health, 22(3), 217–224. https://doi.org/10.1080/26895269.2021.1904330

Department of Health and Social Care (2021). NHS Constitution for England. https://www.gov.uk/government/publications/the-nhs-constitution-for-england

Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 116–123. https://doi.org/10.1016/j.jaac.2016.10.016.

Gibson, D. J., Glazier, J. J., Olson, K. R. (2021). Evaluation of anxiety and depression in a community sample of transgender youth. JAMA Network Open, 4(4), e214739. https://doi.org/10.1001/jamanetworkopen.2021.4739.

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L, & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. https://transequality.org/sites/default/files/docs/usts/USTS-AIAN-Report-Dec17.pdf

National Health Service Health Research Authority (2022).  UK Policy Framework for Health and Social Care Research. https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/uk-policy-framework-health-and-social-care-research/#allresearch

Office of National Statistics (2021). Data and analysis from Census 2021. Population estimates. https://www.ons.gov.uk/peoplepopulationandcommunity

Olson, K. R., Durwood, L., Horton, R., Gallagher, N. M., & Devor, A. (2022). Gender identity 5 years after social transition. Pediatrics, 150(2), e2021056082. https://doi.org/10.1542/peds.2021-056082

Pariseau, E. M., Chevalier, L., Long, K. A., Clapham, R., Edwards-Leeper, L., & Tishelman, A. C. (2019). The relationship between family acceptance-rejection and transgender youth psychosocial functioning. Clinical Practice in Pediatric Psychology, 7(3), 267. https://doi.org/10.1037/cpp0000291

Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503–505. https://doi.org/10.1016/j.jadohealth.2018.02.003

Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53(6), 791–793. https://doi.org/10.1016/j.jadohealth.2013.07.019.

Steinberg, L. (2013). Does recent research on adolescent brain development inform the mature minor doctrine? The Journal of Medicine and Philosophy, 38(3), 256–267. https://doi.org/10.1093/jmp/jht017

Temple Newhook, J., Pyne, J., Winters, K., Feder, S., Holmes, C., Tosh, J., Sinnott, M., Jamieson, A., & Pickett, S (2018). A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism, 19(2), 212-224. https://www.tandfonline.com/doi/full/10.1080/15532739.2018.14563907.

Vrouenraets, L. J. J. J., de Vries, A. L. C., de Vries, M. C., van der Miesen, A. I. R., & Hein, I. M. (2021). Assessing medical decision-making competence in transgender youth. Pediatrics, 148(6), e2020049643. https://doi.org/10.1542/peds.2020-049643

Weithorn, L.A., & Campbell, S.B. (1982). The competency of children and adolescents to make informed treatment decisions. Child Development, 53(6), 1589-1598. https://doi.org/10.2307/1130087

World Health Organization (2017). Human rights and health. https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health

Yogyakarta Principles.org. (2007). Yogyakarta principles. https://yogyakarta.org

FOR THE FULL RESPONSE IN PDF, CLICK HERE.

The World Professional Association for Transgender Health (WPATH) Standards of Care 8 are published here. You can also view them on the PATHA website here. Below is from the WPATH Press Release:

Following five-years of rigorous scientific effort by more than 120 health care clinical and academic professionals across the globe, the World Professional Association for Transgender Health (WPATH) has released the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC8). Building upon the Standards of Care Version 7, which were released in 2012, the SOC8 provides clinical guidance for health care professionals to assist transgender and gender diverse (TGD) people with safe and effective pathways to achieve lasting personal comfort with their gendered selves, and to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, hormonal or surgical treatments, gynecologic and urologic care, reproductive options, voice and communication therapy, and mental health services (e.g., counseling, psychotherapy), among others.

“The Standards of Care 8 represents the most comprehensive set of guidelines ever produced to assist health care professionals around the world in support of transgender and gender diverse adults, adolescents, and children who are taking steps to live their lives authentically,” said WPATH President Walter Bouman, MD, PhD, and WPATH President Elect Marci Bowers, MD. “Health care is a human right. All trans-identified people on this planet deserve the same opportunity to be their true selves and have access to the medically necessary affirming care that allows them to do just that. The field of transgender medicine is evolving rapidly, responsive foremost to the needs of patients and their families and guided by objectivity, compassion, and consensus. We are thrilled to provide this vital resource to support transgender and gender diverse people worldwide.”

The SOC8 guidelines committee consisted of multidisciplinary subject matter experts, health care professionals, researchers and stakeholders with diverse perspectives and global geographic representation. Consensus of final recommendations were based upon extensive reviews of the literature and were attained using an iterative Delphi process, which involved multiple rounds of revisions based upon careful review by the authorship team that included all members of the guidelines committee.

In December 2021, a draft of the SOC8 was released to the public for review and comment. WPATH received thousands of comments on the guidelines. All were read and taken into consideration during the editing phase of SOC8. “Watching with great pride and respect as the entire SOC8 revision committee worked in a collaborative way to develop these robust, and revised guidelines was a phenomenal experience,” said Blaine Vella, WPATH’s Executive Director. “The authors worked tirelessly, as volunteers, to ensure that their chapters were representative, balanced, and contained the most current scientific data and clinical experience available. All this in the knowledge that the SOC8 will continue to offer access and knowledge to the health and wellbeing of all transgender and gender diverse people across the globe.”

“The Standards of Care 8 is here to help people get the care they need so they can live healthy, happy lives. We are not starting from scratch. We are building upon decades of research and clinical experience,” said SOC8 Co-Chairs, Eli Coleman, PhD, Jon Arcelus, MD, PhD, and Asa Radix, MD, PhD, MPH. “The SOC8 is the most expert, nuanced, evidenced-based and consensus-based document internationally. The authors come from a variety of disciplines working in transgender health. All have done their utmost to serve a broad public and a broad area of health care providers with guidelines they can work with in different places around the world. We hope it serves the quality of care for transgender people.” Link to full Standards of Care 8 here.

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WPATH is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. Founded in 1979, the organization currently has over 3,000 health care professionals, social scientists, and legal professionals, all of whom are engaged in clinical practice, research, and education that affects the lives of TGD people. WPATH envisions a world wherein people of all gender identities and gender expressions have access to evidence-based healthcare, social services, justice, and equality.

In response to concerns about long waiting lists and accessibility problems in the centralised gender identity service for children and young people in the United Kingdom, the interim report from the Cass Review has recently recommended “commissioning a national network of regional services across the country over the coming years”. The PATHA Executive Committee is concerned that this has led to media reports suggesting that the recommended closure of the current service is due to “safety concerns”. In fact, the UK National Health Service’s response has focused on ways to “improve and expand the support offered to children and young people who are questioning their gender identity”. This approach would increase services as well as accessibility and be more similar to how gender affirming care is provided for children and young people in Aotearoa New Zealand. 

Some media reports have mentioned the use of puberty blockers. In Aotearoa New Zealand, these are prescribed based on a carefully considered decision made by the young person and their family in partnership with the health team, where the benefits are considered to outweigh potential risks.

PATHA supports the use of a gender affirmative approach to care, which is based on listening to the individual person and working with them to achieve the outcomes that are most appropriate for their individual needs. The PATHA Executive Committee is concerned about statements in the Cass Review questioning this approach and urges the Review to consider the international evidence more widely.

The PATHA Executive Committee endorses the recent AusPATH statement on this matter, which gives further details and context. This includes a link to a British Medical Journal editorial regarding this interim Cass report, whose title reiterates the need for the review to be based solidly on existing international evidence and consensus. The full AusPATH statement is copied below:

1. There have been articles in the Australian media recently about the Cass Review. These articles have misleadingly suggested that the recommended closure of the Gender Identity Development Service by the Cass review is due to “safety fears” and “rushing children into treatment”. These articles have prompted this statement by the Board of AusPATH.

2. The Board of AusPATH notes that in the UK, all gender identity services are provided by a single specialist clinic called the Gender Identity Development Service (GIDS) through the Tavistock and Portman NHS Foundation Trust. The Review has proposed the prompt development of regional centres that will develop links and work closely with local services. A system of regional centres working with local providers would be very similar to the model that provides care for children and young people with gender incongruence in Australia. Potentially, more regional centres would mean that services are more accessible especially if there is investment to increase the amount of services provided. These regional centres could also assist in the training of the local medical workforce.

3. The Board of AusPATH is concerned about the use of language in the review that talks about causation of gender incongruence. Such language is often used as a preamble to conversion therapy, which the Board of AusPATH unequivocally opposes.

4. The Board of AusPATH is concerned about statements in the review questioning an affirmative approach to gender affirming care. An affirmative approach is about listening to the individual person and working with them to achieve the outcome that is most appropriate for each individual person and this is consistent with a person-centered approach to health care. The Board of AusPATH supports the use of an affirmative approach to gender affirming care.

5. The Review suggests putting in place standardised approaches to the assessment of children and young people with gender incongruence that also includes a full mental health and neurodevelopmental assessment. In Australia, a full psychiatric/psychological assessment which can include a neurodevelopmental assessment is done before the commencement of medical treatment. The Board of AusPATH is aware of evidence showing that children and young people with gender incongruence often have high rates of mental health concerns and neurodiversity. Identifying these early and putting in place strategies to identify these concerns and support for managing them is appropriate. The Board of AusPATH do not support“ exploratory therapy” which is often used as a euphemism for conversion therapy.

6. The Review suggests putting in place research protocols to support long-term data collection with the consent of participants and the Board of AusPATH is supportive of this proposal. This is also common practice in Australia.

7. The Board of AusPATH considers that there is significant international evidence about the use of puberty blockers and gender-affirming hormone treatment for young people with gender incongruence. There is also accumulating evidence of the harm that ensues from denying puberty blockers and gender affirming hormone treatment. We urge the Review to consider the international evidence more widely. The Review has not said what model it proposes as an alternative to gender
   affirming care nor what evidence it has for any alternative model.

8. The Board of AusPATH urges any further development of policy regarding the care of children and young people with gender incongruence to work closely with young people and their families and peer-led services as well as clinicians who have experience and expertise in working with his population. We also urge the Review to consider getting input from international experts in this area.

9. The Board of AusPATH would like to draw attention to the excellent editorial in the British Medical Journal, regarding this interim report authored by Assoc Prof Ken Pang, Mr Jeremy Wiggins and Assoc Prof Michelle Telfer. Access it here.

https://auspath.org.au/2022/08/11/auspath-statement-about-the-independent-review-of-gender-identity-services-for-children-and-young-people-interim-report-february-2022-in-the-uk-cass-review/ 

A collaborative article by members of the PATHA Executive Committee and AusPATH Board of Directors has been published in the Australian and New Zealand Journal of Psychiatry (ANZJP). This article responds to the Royal Australasian and New Zealand College of Psychiatrists (RANZCP) Position Statement on Gender Dysphoria and calls for them to review their statement.

In November 2021, PATHA, AusPATH, and ACON also sent an open letter to the President of the RANZCP, also calling for a review of this position statement. This letter was also signed by 20 community-controlled organisations across the two countries.

You can view the article on the ANZJP website, and the text is below. We are very grateful to Sav Zwickl for leading this article.

Re: The RANZCP position statement on gender dysphoria

Sav Zwickl, Belinda Chaplin, Fiona Bisshop, Teddy Cook, Clara Tuck Meng Soo, Belinda Birtles, Jaimie Veale, Rona Carroll, Rachel Johnson, Joey Macdonald, Jesse Porter, Cassie Withey-Rila, Zoe Kristensen, Ashleigh Lin

As members of the Board of Directors for the Australian Professional Association for Trans Health (AusPATH) and the Executive Committee of the Professional Association for Transgender Health Aotearoa (PATHA), we are deeply concerned by the updated RANZCP Position Statement 103 ‘Recognising and addressing the mental health needs of people experiencing Gender Dysphoria/Gender Incongruence’. We have many decades of experience in trans healthcare between us, including lived expertise as trans people – both binary and non-binary, and/or in clinical, research and community practice. We consider the approach taken by RANZCP to trans people as inappropriate and harmful.

Historically, psychiatry has played a central role in the pathologisation of those seeking medical gender affirmation. Gatekeeping, the process by which gender affirming care has been withheld or controlled by the medical field, has been widely practiced in psychiatry, neglecting a patient-led, informed consent approach. As we outline below, the recent RANZCP position statement frames the trans experience as inherently pathological. This is in direct conflict with World Health Organization, American Psychiatric Association, World Professional Association for Transgender Health, AusPATH and PATHA, all of whom make it clear that being trans is not a pathology.

Through selectively citing research and treatment guidelines, the position statement equates peer-reviewed evidence with ‘professional opinion’ and the notion of supporting trans people as a ‘debate’. Important research such as Trans Pathways (Strauss et al., 2017) in Australia and Counting Ourselves (Veale et al., 2019) from Aotearoa New Zealand are notably missing from the position statement. These represent some of the largest studies ever conducted in this region about the mental health and care pathways of trans people, including trans young people, and clearly demonstrate that supporting and affirming trans people are a protective factor against psychological distress, self-harm and suicidality. The benefits of gender affirming hormones and surgery are well documented in alleviating gender dysphoria and improving mental health and quality of life (e.g., Hembree et al., 2017). Further, while some people have expressed concern about supposedly high incidences of ‘transition regret’ and ‘detransition’, these claims are largely unfounded. Regret related to gender affirming hormones and surgery is extremely rare; the largest study to date, which involved 6793 trans people followed between 1972 and 2015, demonstrated a surgery regret rate of just 0.5% (Wiepjes et al., 2018). Data also demonstrate that those people who do ‘detransition’ do so predominantly due to extrinsic factors, such as discrimination, rather than no longer being trans. A number of these people do go on to ‘retransition’ or resume transition at a later date, although unfortunately there is often inadequate follow up to document this.

While trans people do indeed experience staggeringly high rates of mental health and psychological distress, this is not inherent to being trans. The position statement completely neglects to acknowledge that high rates of mental distress and suicidality in trans populations are largely attributable to external factors. These include facing daily discrimination and stigma and experiencing rejection and violence within the home, employment, education, justice system and across many other domains of life (Strauss et al., 2017; Veale et al., 2019). Of most relevance to psychiatry, adolescents who have faced denial and delayed access to social and medical affirmation are significantly more likely to experience mental distress (Turban et al., 2022).

The pathologisation of trans people by the RANZCP further perpetuates stigma. Since the position statement was published, we have observed it being used nefariously, with harmful outcomes. For example, the position statement has been cited in submissions that support conversion practices for the New Zealand Conversion Practices Prohibition Legislation and in legislative advocacy in some US states seeking to ban access to gender affirming healthcare for young people.

Given that being trans is not a pathology, psychiatry’s place in trans healthcare today should be limited to working with mental health concerns, which are faced by trans people inequitably due to stigma, lack of support, discrimination and prejudice. With the depathologisation of trans experiences and the shift to a patient-led, informed consent model of care in both Australian and Aotearoa New Zealand, general practitioners, endocrinologists and sexual health specialists are routinely prescribing gender affirming hormones to trans adults without the involvement of mental health professionals or the necessity of a diagnosis of Gender Dysphoria (as per the DSM-V). In trans individuals above the age of 18 years, the majority seeking gender affirming hormonal or surgical intervention only require a psychiatric or psychological opinion when underlying medical or psychiatric conditions could reasonably impact their capacity to provide informed consent. These assessments should purely be for the purposes of determining capacity and should be indistinguishable from an assessment of capacity for a cisgender individual seeking to undergo a medical procedure. It may also be appropriate for psychiatrists to consider prescribing gender affirming hormone therapy themselves (with appropriate safeguarding, support and oversight) as a treatment to alleviating the distress (and associated, e.g. depression and anxiety) arising from gender dysphoria.

In conclusion, the RANZCP position runs directly counter to the well-established evidence base that gender affirmation improves health outcomes and strengthens quality of life. Unreasonable barriers to access and outdated and harmful arbitrary protocols, can only lead to poorer health and wellbeing outcomes for trans people across the lifespan, including young people. Unfortunately, some trans people lose their life through suicide due to the lack of access or denial of appropriate healthcare and gender affirming treatment. To avoid this, health professionals should follow contemporary, evidence-based practice guidelines, such as those endorsed by AusPATH and PATHA, and engage in ongoing professional development.

As members of the trans community, researchers and clinicians dedicated to providing gender affirming care, we urgently and respectfully ask that the RANZCP review their position statement.

Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

References

	Hembree, WC, Cohen-Kettenis, PT, Gooren, L, et al (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism 102: 3869–3903. Google Scholar | Crossref | Medline
	Strauss, P, Cook, A, Winter, S, et al (2017) Trans Pathways: The Mental Health Experiences and Care Pathways of Trans Young People. Summary of results. Perth, Australia: Telethon Kids Institute. Google Scholar
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