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
	Turban, JL, King, D, Kobe, J, et al (2022) Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One 17: e0261039. Google Scholar | Crossref | Medline
	Veale, J, Byrne, J, Tan, KK, et al (2019) Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Hamilton, New Zealand: Transgender Health Research Lab. Google Scholar
	Wiepjes, CM, Nota, NM, de Blok, CJ, et al (2018) The Amsterdam cohort of gender dysphoria study (1972–2015): Trends in prevalence, treatment, and regrets. The Journal of Sexual Medicine 15: 582–590. Google Scholar | Crossref | Medline

PATHA has created a document that provides a vision for transgender healthcare in the context of the current health reforms. We created it to give PATHA members a chance to have their say and give feedback about what our association is proposing to the Associate Minister of Health and the Ministry of Health. Another reason for creating this document is to inform PATHA members and the general public about what PATHA is seeking in this consultation.

You can read more and download the document on this page.

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 18th of June, 2022.

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 Report
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.

The Professional Association for Transgender Health Aotearoa (PATHA) welcomes today’s Budget announcement of $2.1M over 4 years to improve transgender and non-binary people’s access to primary health care services.

“In November 2020, PATHA’s Briefing to the Incoming Minister of Health emphasised the urgent need for an action plan to ensure equitable health outcomes for transgender people”, said PATHA President Dr Jaimie Veale. “Today’s Budget is an important step towards delivering reliable public access to gender-affirming healthcare, and a wider health system that delivers healthcare that is safe, equitable, and effective for transgender people”.

“Trans and non-binary people deserve equitable access to quality, gender-affirming health care in their local area”, said PATHA Vice-President Dr Rona Carroll. As a practicing GP I know how essential it is that primary care is well supported to do this work, and am keen to see how this will look at the implementation stages”.

PATHA looks forward to working closely with the Minister and her officials on ensuring primary and community providers have sufficient funding, guidelines, and training to deliver gender-affirming services, and that referral pathways link trans and non-binary people to publicly funded secondary services.

PATHA advocates for the health, wellbeing and rights of transgender people. “This requires partnerships with trans and non-binary communities that recognise people’s rights to bodily autonomy, self-determination and to make their own health decisions based on informed consent”, said Dr Veale.

“Those rights apply to intersex people too, so PATHA strongly supports today’s commitment of $2.5M to introduce a rights-based approach to health care for intersex children and young people”.

ENDS

Contact: Dr Jaimie Veale

Emails: PATHA (info@patha.nz) Dr Jaimie Veale (jaimie.veale@waikato.ac.nz)

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Background Information:

The Professional Association for Transgender Health Aotearoa (PATHA) is an interdisciplinary professional organisation working to promote the health, wellbeing and rights of transgender people. We have over 200 members who work professionally for transgender health in clinical, academic, community, legal and other settings.

https://patha.nz/

PATHA’s November 2020 Briefing to the Incoming Minister of Health: https://patha.nz/2020-briefing

The PATHA Training Day 2021 is available to view on Youtube.

A practical introduction to working with trans and non-binary people in Aotearoa, the intended audience for these two videos are those working in the health and disability sector in both clinical and non-clinical settings, including allies. As with the previously uploaded symposium presentations, the kaikōrero have made these videos open access - so please feel free to uplift and share their mahi.

The kaimahi and kaikōrero involved have put in additional work to have these presentations accessible. The PATHA Organising Committee extends their warmest thanks! Beautiful work!

Dr Jeannie Oliphant followed-up the 2019 survey of District Health Board (DHB) clinicians, with a 2021 update at the PATHA Symposium this year. She obtained information from clinicians providing gender affirming healthcare in 20 DHBs in New Zealand.

In summary, while there has been an improvement in the availability of gender affirming healthcare services provided by DHBs around Aotearoa, this has mostly been due to efforts to improve access to clinical services. It should be acknowledged that provision of clinical services is often championed by individual clinicians in contrast to other aspects of care such as providing clear pathways or advisory groups, which require resourcing by DHB management.

You can read the full findings here: https://patha.nz/gender-affirming-care-2021

On 5 November 2021, AusPATH, PATHA and ACON submitted a joint letter to the President of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), calling for a review of the Position Statement “Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence”.

This letter (attached below) was co-signed by 20 national and state-based community-controlled organisations, representing every state and territory across Australia, and Aotearoa New Zealand.

AusPATH, PATHA and ACON decided that this letter be published in order to support broader advocacy efforts.

You can download the letter here.

PATHA recently made submissions to two of Parliament's Select Committees on proposed laws that will impact on trans people's wellbeing.

On the Conversion Practices Prohibition Legislation Bill, PATHA made a submission in support of banning conversion practices, and made recommendations to strengthen the definitions used in the Bill, include protections for intersex people, introduce broader penalties, resource education for communities and support for survivors, and require a review of the law's implementation.  

• Submission on the Conversion Practices Prohibition Legislation Bill
• Oral submission to the Justice Committee (starts at about 14:10)

On the Inquiry into Supplementary Order Paper (SOP) 59 on the Births, Deaths, Marriages and Relationships Registration Bill, PATHA made a joint submission with the Counting Ourselves research team at the Transgender Health Research Lab, at the University of Waikato. The submission supported the proposed law change, and recommended improvements to address gaps in access to legal gender recognition for asylum seekers, refugees and migrants; improve access for children and young people; affirm the existing rights of trans, non-binary and intersex people; and ensure their participation in the development of implementing regulations and the five-year review.

• Submission on the Inquiry into Supplementary Order Paper 59 on the Births, Deaths, Marriages and Relationships Registration Bill from the Counting Ourselves research team at the University of Waikato Transgender Health Research Lab and PATHA.
• Oral submission to the Governance and Administration Committee (starts at about 34:00)

PATHA welcomes the news that the 'Bell vs Tavistock' case in England has been unanimously overturned on appeal. We are pleased by the ruling's judgment that the long-standing standard of Gillick competence for young people to consent to their medical care should apply the same to transgender youth as it does to any other youth. You can read the judgement here, or these summaries of its main points: quick read, longer read.

Last year, PATHA joined WPATH, EPATH, USPATH, AsiaPATH, CPATH, and AusPATH in a statement opposing the earlier judgement, noting that it would result in significant harm to affected transgender young people and their families, and urging that this earlier judgement be overturned.

The Annual General Meeting for the Professional Association for Transgender Health Aotearoa (PATHA) will be held via online video call from 1-3pm on Saturday the 19th of June, 2021.

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 Report
6. Election of Executive Committee Members
   
7. Upcoming Symposium and Training Day
   
8. Close meeting
   

PATHA members can log in to find a registration link for the online AGM, copies of the reports, and information about nominees for the Executive Committee.