PATHA's Annual General Meeting (AGM) will be held via Zoom from 2-3pm on Saturday 30 August 2025. All members are welcome.

AGM Agenda:

1. Welcome

2. Noting of any apologies and appointing of minute taker

3. Receiving the minutes of the 2024 AGM

4. President’s Report

5. Treasurer's Report and PATHA's annual financial statements

6. Election/appointment of PATHA's 2025-26 Executive Committee

7. Motion to replace PATHA's Rules with a new Constitution

8. Close meeting

The Professional Association for Transgender Health Aotearoa (PATHA) is deeply concerned at further delays to the publication of updated Guidelines for Gender Affirming Healthcare in Aotearoa New Zealand.

PATHA has been informed by Te Whatu Ora | Health New Zealand that the updated Guidelines will not be published until the Minister of Health decides on whether to introduce regulations on the ability of medical professionals to prescribe puberty blockers as part of gender affirming healthcare.

The guideline’s advice on prescribing puberty blockers was updated in November 2024 to reflect the Ministry of Health’s position statement on the use of these medications. This advice spans just 6 of the total 182 pages of information contained in the guidelines. The guidance is evidence-based, aligns with international best practice and guidelines, and supports a holistic approach to gender affirming medical care for young people who need it.

“Medical professionals working in this area are constantly being asked by colleagues for clinical guidance on gender-affirming healthcare,” says Dr Rona Carroll, a Specialist General Practitioner and Vice-President of PATHA. “By not publishing the updated guidelines, the government is stopping healthcare providers from being guided by evidence-based, up-to-date New Zealand specific information. We have been given no timeframe for when to expect a decision about the puberty blocker consultation or the updated guidelines. Considering how many other areas of health these guidelines include, and that the advice on prescribing puberty blockers is in line with the Ministry’s position statement, the updated guidelines should be published immediately. I think clinicians would be providing safer care if they had access to these guidelines today.”

On Wednesday, 28 May, PATHA published an open letter calling on the Minister of Health, Simeon Brown and the Associate Minister for Health, Matt Doocey, to release the updated guidance.

This letter was signed by over 500 medical bodies, clinicians and community organisations. Signatories include the Royal New Zealand College of General Practitioners, the New Zealand Society of Endocrinology, the College of Child and Youth Nurses, and the Paediatric Society of New Zealand.

The evidence-based guidelines, which have been peer reviewed by clinicians with expertise in this care from within New Zealand and internationally, provide detailed information on a wide range of topics relevant to healthcare for transgender and non-binary people. This includes several revised chapters from the 2018 edition in line with emerging medical research.

“I’m proud of the amount of work the authors have put into these guidelines, bringing their extensive collective expertise into creating guidance that is broad and has a holistic view of transgender health,” says Jennifer Shields, PATHA President. “These guidelines cover so much more than puberty blocker medication, and this information is important for all healthcare workers to have.”

“It is clear that there is no evidence-based justification for considering restrictions on prescribing puberty blockers to transgender young people,” Shields says. “These medications continue to be prescribed to children for other indications, and limitations in the quality of the academic evidence are not unique to this care. Healthcare professionals are now left wondering if this government is being pulled into alarming ‘culture war’ trends away from best practice medical care, and into anti-transgender policies that lead to a reduction in patients' rights and freedoms, and set precedent for making clinical decisions based on political beliefs rather than what’s best for patients.”

“This is clear evidence of ideological interference in an operational, professional frontline medical resource that is being requested by the health sector,” Carroll said. “We reiterate our call for the Government to allow Te Whatu Ora Health New Zealand to publish these updated guidelines immediately.”

Background information

Statement on puberty blockers

On 21st November 2024, the Ministry of Health published a position statement on the use of puberty blockers in gender affirming care, emphasising that puberty blockers could continue to be prescribed when needed as part of interdisciplinary teams. The Government expressed an intention to explore further restrictions on access to this care, and opened public consultation on possible restrictions. This consultation closed on 20th January 2025.

A memo sent to then Minister of Health Shane Reti on 30 April 2024 was released to PATHA under the Official Information Act. In this memo, the Ministry of Health clarified that:

“There is currently no evidence that individual clinicians are prescribing [puberty blockers] outside of an interprofessional team.”

This shows that concerns about individual professionals prescribing puberty blockers inappropriately are unfounded, and current prescribing practices are already in line with the Ministry’s position statement.

PATHA previously published a collective statement opposing the restrictions the Government is considering on the prescription of puberty blockers to transgender young people. This statement also received broad support from medical bodies, including the New Zealand Paediatrics Society and the New Zealand Society of Endocrinology. The statement reads [in part]:

“The Ministry of Health Evidence Brief identified that any evidence of harm associated with providing puberty-blocking medication is limited and inconclusive, and withholding this care may exacerbate gender dysphoria and negatively impact mental health. Equitable and non-discriminatory access to this care should be provided and maintained throughout the country.

Decisions about prescribing puberty blockers should continue to be made collaboratively between young people, their families or support people, and the health professionals involved in their care. These decisions are individualised, based on informed consent, and guided by professional training, clinical experience, and the best available evidence. Any move to restrict access to puberty blockers would be a political decision and not one based on clinical guidance from health experts in New Zealand and international best practice. Medical decisions should remain free from political interference.”

Background on puberty blockers

Puberty blockers are a medication called gonadotrophic releasing hormone (GnRH) agonists. They were developed in the 1980s for use in much younger children with precocious (early) puberty, and have been used in gender affirming care for over 20 years. They halt the development of secondary sexual characteristics, such as breast growth or voice deepening, and can relieve distress associated with these bodily changes for transgender young people. Puberty blockers have the benefit of allowing the young person time before making any decisions regarding starting on gender affirming hormone therapy.

The effect puberty blockers have on pausing pubertal changes is reversible. Once the puberty blocker medication has been stopped, puberty will resume as it would have done without medication.

All medications have known or potential risks, but evidence and experience to date does not raise significant concerns about the safety of puberty blockers. As is the case in all medical prescribing, risks, side effects and benefits of medications are discussed with patients as part of the informed consent process before prescribing.

There are also risks to not prescribing medications when they are indicated. Puberty results in irreversible physical changes, which can result in lifelong distress and gender dysphoria for some transgender people.

In every area of healthcare, decisions about treatment and medication prescribing take all of these aspects into account, and health professionals support patients and their families to weigh up the pros and cons for their individual situation. Gender affirming healthcare is no different. Decisions about whether to start puberty blockers are made between health professionals, young people and their whānau. These are healthcare decisions which should remain free from ideological political interference.

Clinicians who initiate puberty blockers should be experienced in providing gender affirming healthcare and working within an interdisciplinary team. It is essential that access to this care and to puberty blocker medication is maintained.

Topics covered by the updated Guidelines

Advice on the prescription of puberty blockers is a small portion of the content covered by the updated guidelines. The updated guidance also includes detailed information on a broad number of other areas of transgender health, including whānau support, creating inclusive clinical environments, non-medical and non-surgical gender affirmation, speech and language therapy, fertility and sexual health, mental wellbeing, gender-affirming hormone therapy, and detransition, as well as specific guidance for Māori, Pasifika, and refugee and asylum seeker trans people.

Official Information Act Releases

In February 2025, the Ministry of Health provided PATHA an OIA release containing a number of memos and briefings provided by the Ministry to the Minister’s office. You can download the full release here.

In March 2025, PATHA requested copies of communications between the Minister and Associate Minister’s offices and Te Whatu Ora Health New Zealand. This request was withheld in full under sections 9(2)(f)(iv) and 9(2)(g)(i) of the Official Information Act. Minister Brown’s response is available here.

Health professionals, health organisations and community organisations are concerned by the delay of the publication of the updated clinical Guidelines for Gender Affirming Care in Aotearoa New Zealand.

Health professionals are asking for updated guidance on providing appropriate and safe healthcare to transgender and non-binary patients. 

In 2023 Health NZ | Te Whatu Ora contracted the Professional Association for Transgender Health Aotearoa (PATHA) to update the 2018 guidelines for gender affirming healthcare. It is standard practice for guidelines to be periodically updated to ensure their content is kept up to date. PATHA submitted the updated guidelines in October 2024 and they followed the standard process for publication of a clinical guideline, including approval from Te Whatu Ora’s National Clinical Governance Group, and were also approved by Te Whatu Ora's Executive Leadership Team.

The evidence-based guidelines, which have been peer reviewed by clinicians with expertise in this care from within New Zealand and internationally, cover a wide range of topics relevant to transgender and non-binary health and wellbeing, including new chapters on creating inclusive healthcare environments, non-medical gender affirmation options, and more. The small section within this comprehensive document relating to prescribing puberty blockers aligns with the Ministry of Health’s position statement on this care and supports safe prescribing for young people.

The guidelines were due for publication at the end of March 2025. We are aware that in the days beforehand, an FYI was sent to the Minister and Associate Minister of Health. Less than 24 hours before the date of publication, there was an unnecessary, indefinite and unexplained delay in the publication of these clinical guidelines. We believe this is due to unprecedented and inappropriate political interference. Delays in releasing these guidelines impacts on the ability to improve healthcare delivery and health outcomes for the transgender and non-binary population. The undersigned call on the government to allow Health NZ | Te Whatu Ora to publish the updated Guidelines for Gender Affirming Healthcare in Aotearoa New Zealand immediately.

Add your name to the letter here.

Signatories:
Medical bodies:
Aotearoa New Zealand Association of Social Workers
College of Child and Youth Nurses | Tapuhitia Ngā Mokopuna Mō Apōpō 
General Practice New Zealand (GPNZ)
The Paediatric Society of NZ | Te Kāhui Mātai Arotamariki o Aotearoa
New Zealand Association of Counsellors
New Zealand College of Clinical Psychologists
New Zealand College of Primary Health Care Nurses
New Zealand Medical Students Association
New Zealand Nurses Organisation | Tōpūtanga Tapuhi Kaitiaki o Aotearoa
New Zealand Psychological Society
New Zealand Sexual Health Society
New Zealand Speech-language Therapists' Association
New Zealand Society of Endocrinology
New Zealand Women in Medicine Charitable Trust
Professional Association for Transgender Health Aotearoa
Rainbow Otago Medical Students Association (ROMSA)
Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Royal New Zealand College of General Practitioners

Other organisations:
Abortion Law Reform Association of New Zealand
Adhikaar Aotearoa
Aotearoa New Zealand Sex Workers Collective 
Auckland Pride
Burnett Foundation Aotearoa
Gender Minorities Aotearoa
He Kāinga Ora
Identify Survey
InsideOUT Kōaro
Intersex Aotearoa
Mana Āniwaniwa
Manuwatū Lesbian and Gay Rights Association
Mental Health Foundation of New Zealand
Moana Vā - Navigator of Pacific Pride
New Zealand Parents and Guardians of Transgender and Gender Diverse Children
Ōtautahi Christchurch Pride
Pride Whanganui
Queerly Legal
Rainbow Auckland
Rainbow Focus
Rainbow Hub Waikato
Rainbow Path
RainbowYOUTH
Rights Aotearoa
School of Health staff, Victoria University of Wellington
Te Kahukura Puāwai
Te Ngākau Kahukura
The Trans Heart Health Project
Tu Ora Compass Health
Qtopia
Q Youth Nelson
Village Collective

Health services:
Anamata clinic Taupō
Aramoho Health Centre
Awhi and Aroha Consultancy
Birth Rite Midwives
Evolve Wellington Youth Service
Gender Care at Tamatea Medical Centre
Gender Care Whanganui
Gender Dynamix
Henderson Counselling & Guidance Services
Hutt Union and Community Health Service
Mauri Ora, Student Health & Counselling
Number 10 Southland Youth One Stop Shop
OutLine Aotearoa
Ranpsych PTY Ltd 
Sexual Wellbeing Aotearoa
Sparrow Consults
Te Aro Health Centre
Te Tahi Youth
University of Otago, Student Health Services
Vibe Youth Health Service
Whangarei Youth Space
Whatever Whanganui - The Youth Health Place
Youth Kinex - Masterton Medical Youth Clinic

Individuals:
Roni Alder, Clinical Psychologist
Beckie Alexander, BHealthSci, Women's Health Coach
Grace Allen, Speech Language Pathologist
Danaë Anderson, PhD
Krystle Anderson
Donna Anderson-Jones
Kristin Antarra, MNZAC
Dr Lauren Antley, MBChB
Verity Armstrong, Masters of Psychotherapy, PBANZ, Waka Oranga
Dr Sue Bagshaw, MB BS FAChSHM FRNZCGP (hon) DNZM
Dr Michelle Bailey, MBchB , dip obs , FRANZCOG, CREI
Bethany Baird
Angela Ballantyne, Professor of Bioethics
Scout Barbour-Evans, Rainbow Health Policy Specialist
Dr Jan Barrett, MBChB, FRNZCGP
Revd. Ann Batten, Anglican Priest
Nic Beets, Clinical Psychologist specialising in Relationship & Sex Therapy
Dr Katie Ben, BSc (Hons) MBBS FRCA MBHL
Dr Karen Benattar, MBBS FRNZCGP FAChSHM
Ryan Bentham, BSocSci(Hons) Psychology
Amanda Berkahn, Counsellor, Addiction Practitioner, DAPAANZ NZAC BCAAP
Tabby Besley, Registered Counsellor
Debbie Blake, PhD
Beauregard Blight, Clinical Psychology Student
Dr Alisa Boucsein, PhD, Youth Diabetes Educator
Nathan Bramwell
Sese Bramwell
Dr Penny Brandt, Paediatrician, BA, DO, FRACP
Luca Bree, Master Health Science, Registered Midwife
Madison Bridges, Registered Social Worker
MJ Brodie
Alex Brown, MBChB MS FRCS FEBS FRACS
Jemima Bullock, Registered Clinical Psychologist and Neuropsychologist
Stephanie Burd, Clinical Social Worker
Dr Marie Burke, General Practitioner, MRCGP(UK) FRNZCGP
Dr Kathy Burt, MBChB, FRACP
Jack Byrne, Honorary Research Fellow and Co-Principal Investigator, Counting Ourselves
Octavia Calder-Dawe, PhD in Health Psychology
Frances Caldwell, Mental Health Facilitator
Dr Sarah Callaghan, MBChB
Chantelle Callagher
Rebecca Campbell, Professor in Physiology, Director of Centre for Neuroendocrinology, PhD
Dr Bex Eliot Canner, General Practitioner
Dr Rona Carroll, General Practitioner, FRNZCGP, MBChB
Sarah Carter, BSLP4 Student
Dr Emily Cavana, BMBS, BSc, FRNZCGP, PGDipHealSc.
Louise Chan, Mātanga Tapuhi | Nurse Practitioner / Master of Nursing
Georgia Chaplyn, Provisionally Registered Psychologist
Victoria Chinn, PhD
Mik Clapson
Kelly Claridge
Dr Dermot Coffey, FRNZCGP
Kathryn Collyns, Public Health Advocate
Dr Glenn Colquhoun, General Practitioner
Joshua Conant
Sheena Conant
Nick Conn, BSc DipPhty, DipMT, CMInstDCMIoD
Rose Cook, Social Worker
Logan Cotter
Amy Couling 
Dr Lucy Cowie, Registered Clinical Psychologist, Doctorate of Clinical Psychology
Dr Landi Cranstoun, FRNZCGP
Loren Creedon, LMC Midwife
Dr Sonja Crone, BHB, MBChB, FRACP
Dr Anne-Marie Cullen, MBCHB, FRNZCGP
Emma Currie, Senior Peer Support Specialist 
Prof Neal Curtis
Carly Cushman 
Dr Charlotte Dale, MBChB
Elle Dagley, Nurse Practitioner
River Dantzler, Peer Support Worker
Shomudro Das, MAppSW
Anny da Silva Freitas, Member of NZAC and Advanced Accredited Gender, Sex and Relationship Diversity Therapist, BA Counselling, BA Community Education, Advanced Specialist Diploma - Gender, Sex and Relationship Diversity Psychotherapy
Sarah Davis
Dr Pauline Dawson, Senior Lecturer, PhD, MMid, RM
Dr Emily Deacon, MbChb, PGDipOMG, PGDipPaed, FRNZCGP
Kiwa Kahukura Denton, Diploma in Youth Work, Bachelor of Youth and Community Leadership
Zoe Deverick, Clinical Psychologist (PGDipClinPsy, M.Sc, MNZCCP)
Candice de Villiers
Dr Robert de Villiers, MBChB
Andrew Devlin
Nic Dorward, BSW
Thomas Dose
Elsie Douglas, MCARN
Abby Driver, Psychotherapist
Leigh Dumpleton
Dr John Dumsday, MBChB FRNZCGP
Elizabeth du Preez, Clinical Psychologist
Nathalie Dussart, Bachelor of Osteopathy
Dr Julia Eddington, MBBS BSc FRNZCGP
Dr Lizi Edmonds, MBChB, FANZCA
Dr Em Edwards, Clinical Psychologist
Emily Eisen, BTch
Rochelle Ellison-Lupena, PhD Māori and Pacific Health
Christina Emery
Christopher Egnot, BSc(hons)
Dr Ekta Escovar MD FRACP (Paeds)
Dr Sharyn Esteves, MBChB, FRNZCGP. FAChPM
Sarah Eynon
Associate Professor John Fenaughty, PhD
Danielle Fentiman, Counsellor
Vik Fern
Dr Indira Fernando, MBChB
Alex Fisher, Registered Nurse
Regina Fisher Van Der Veen
Koral Fitzgerald
Wendy Fletcher, Speech & Language Therapist
Cinder Aurora Forbes-Duthie
Patricia Ford, Registered Psychotherapist, Master in Counselling
Bridget Forsyth
Dr Julian Foster, MBChB, FRNZCGP
Elspeth Fougere, BDes, RMT, SAr
Sandra Fowler, BA, MA(Hons), DipClinPsych. Registered Clinical Psychologist
Brodie Fraser, Senior Research Fellow, Department of Public Health, University of Otago
Gloria Fraser, PhD, MNZCCP
Dr Vivian Fu, MBChB PhD FRACP
Anthony Gallagher, Social Worker
Dr Martin Gardner, MBChB, FRNZCGP
Sarita Gargiulo, RM, BM, MMid
Sue Garrett, Senior Lecturer
Lewis Garton, BSc
Artemis Gaudin, BSc
Dr Madeline Gee, MBChB FRNZCGP
Dr Victoria George, MBBS MRCPCH FRACP
Dr Angela Glew, MA MB BChir FRNZCGP 
Isabel Goodhue, Registered Nurse
Nathaniel Gordon-Stables
Brigette Gorman, PhD and PGDipClinPsych
Lee Grabarek,  Counsellor (Provisional NZAC), MCouns
Katie Graham, PhD Lecturer in Health Psychology 
Eddy Grant, MSc (psychology) in Nonbinary Identity Development and Wellbeing
Dr Rosie Grant, MBChB
Associate Professor Dr Ben Gray, FRNZCGP(dist) MBChB MBHL
Tessa Green, Nurse Practitioner 
Lou Greene-Winters, Counsellor
Sian Gregan, Registered Nurse
Maeve Gresham 
Dr Marilyn Griffiths, Specialist General Practitioner, MBChB, DCH, FRNZCGP
Dr Bethany Growns, PhD
Nigel Guy, Registered Nurse and Counsellor
Shanan Halbert, Spokesperson for Rainbow Issues- Labour Party
Einstein Hale, MEd, PBANZ, DAPAANZ, MAPANZ
Dr Jennifer Hall, BMedSci (Hons); MBChB; DRCOG; MRCGP; FRNZCGP; PGCertWHlth
Scott Hall, BSc
Walter Hamer, Psychologist
Tommy Hamilton, Narrative Therapist
Sharee Hancock, Registered Nurse
Margaret Hand, Nurse Practitioner
Dr Gina Hart, GP Registrar
Dr Fintan Harte, MA MB BCh DipObs DCH FRCPsych FRANZCP
Jayne Hartstone, PGDip Clin Psych, MSocSc
Dr Jennifer Hayward, FRANZCOG, FChSHM accredited MEDSAC Forensic Examiner BMBS, BMedSci
Jessica Heaton, Intern Psychologist 
Evelyn Hein
Dr Susan Helman, MBChB FRNZCGP
Gemma Henderson, Midwife
Dr Huhana Hickey MNZM, LlB/BSocSci, LlM with distinction, PhD
Caitlin Hickman, Registered counsellor with NZAC
Dr Rachel Highton, MBCHB, FRNZCGP
Jo Hilder, Senior Research Fellow, Otago University Wellington
Dr Madelin Hobson, General Practitioner
Katie Hoek, Child and Family Psychologist
Dr Pauline Horrill, FRNZCGP
Edit Horvath, MSocSci (Hons), COP Sex Therapy
Jove Horton
Philippa Howden-Chapman, Professor of Public Health
Skyler Hsieh, Intern Clinical Psychologist
Dr Debbie Hughes, FRNZCGP MB BCh DCH PGCertHS (Youth Health)
Juno Hunt, Enrolled Nurse
Archie Hunter
Dr Ed Hyde, MBChB, FRANZCOG
Milla Inkila, MEd
Jaina Jacobs, BSc
Dr Chris Jacques, MBChB, Diploma of Child Health, FRNZCGP
Dr Brendan Jansen, MBBS FRANZCP 
Ella Jenkins
Katrina Johnson, School counsellor
Dr Rachel Johnson, MBBS , FRACP (Paeds, AYAM)
Dr Heather Johnston, MBChB, PGDipOMG, IBCLC
Abigail Jones
Maire Joy, Bachelor Counselling, Post Grad Sexology
Andrew Jull, RN, PhD, Professor of Nursing
Marik Kardel
Emma Kelly
Áine Kelly-Costello 
Fleur Kelsey, Registered Midwife, Senior Lecturer School of Midwifery, Otago Polytechnic
Dr Amy Kempthorne, MBCHB RNZCGP
Dr Jonathan Kennedy, General Practitioner
Dr Helen Ker, MBChB
Maria Kovács, Registered Social Worker
Dr Zoe Kristensen, BSc(Hons), MBChB, FRANZCP
Dr Ella Kroch, DClin Psych, MNZCCP
Julia Laing, RCompN, MHSc
Charlene Lang, Registered Clinical Psychologist
Dr Miriam Larsen-Barr, DClinPsych
Sarah Shen Laus, BSN
Dr Kim Lawson, MBChB, Dip Obst, DCH, Dip MSM, FRNZCGP
Morag Lawson, MNSc, Nurse Practitioner
Emily Leadbitter, Registered Nurse
Rosie Leadbitter, Health Workforce Educator & Consultant
Lori Leigh, PhD
Dr Alanah Lin, MBChB, FRANZCP
Jennifer Linsell, MBCHB
Laressa Lynch, MNZAC
Ky Ma
Dr Sophie Mace, MBChB PGDipOMG FRNZCGP IBCLC
Kayla Mackie, Clinical Psychologist
Emma MacKenzie, MWRM, PGDipSc; Kaitiaki/Crisis Line Worker
Dr Alice MacLachlan, General Practitioner
Athena Macmillan, BA(Hons) in Anthropology, PGDip in Bioethics & Health Law
Mason Malcolm, Registered Social Worker
Dawn Maley, Dip Massage Therapy, Dip Clinical Aromatherapy
Larissa Marno, PhD Candidate
Awhi Marshall
Dr Antoinette Martin, General Practitioner
Katherine Martin, Rainbow Education Specialist
Russel Willard Masnayon, BSN, RN
Dr Ruth Mason-Battley, MBChB, Psychiatry Registrar
Duncan Matthews, MNZM, MSCL
Lauren May
Amy McBride, NZCS, BSc, BNursing, PGDip Nursing
Joleen McEvoy, Social Worker
Dr Miranda McEwan, MBChB BSc(Hons) PhD
Harrison McKay, Enrolled Nurse
James McKie, Registered Clinical Psychologist
Dr Kennedy Mclachlan, PhD, Registered Clinical Psychologist
Sharon McLennan, PhD, health researcher
Rosie McMenamin, Youth Health Service Manager
Sarah McNeil, Doctor of Clinical Psychology
Trish McNutt, Registered Nurse
Wendy McPhillips, Nurse Practitioner Mātanga Tapuhi 
Mel Meates, Registered Nurse
Yvette Merrin, BAppSci Health Promotion, certified Health Coach
Cass Mill
Suzanne Miller, Associate Professor, PhD, RM
Dr Ellen Miller, General Practitioner
Mani B Mitchell, Counsellor/psychotherapist member of NZAC
Dr Tania Moerenhout, GP, FRNZCGP, Senior Lecturer
Billy Moore, Medical student
Dr Julia Moore, Consultant Child and Adolescent Psychiatrist 
Dee Morgan
Lani Morris, BA, MBA, MSc
Lara Moses, MSW
Leisa Munro, MA EdMgmt, Dip Tch, Dip Couns
Dr Nicola Munro, MBChB, DRCOG, FRNZCGP
Dr Roslyn Munro, Clinical Psychologist DClinPsych
Jasper Nacilla, Nurse Practitioner
Dr Ruth Nagle
Denise Nassenstein, Trauma therapist (ACC)
Eva Neely, PhD Public Health
Dr Vanessa Ng, FRNZCGP
Rachael Nicoll 
Dr Rebecca Nicholls, GP, BSc, MBChB, FRNZCGP
Megan Norris, B.A., M.Sc.
Liora Noy, Registered Nurse
Papa Nukunuku 
Judy O'Brien, BA Psychology
Dr Caitlyn O'Fallon, MBChB, DCH, FRNZCGP
Lee O'Neill
Arlene Oram, Midwife
Bridget Orchard, Social Work Therapist
Tika Ormond, Speech Language Therapist, Clinical Educator
Ross Palethorpe, MNZAC
Dr George Parker, Midwife, Senior Lecturer in Health Service Delivery, Lead Investigator Warming the Whare Project
Dr Sophie Parnham, FACEM FDRHMNZ
Raewyn Parsons
Nicola Paton
Mershen Pillay, Speech Therapist/Audiologist
Anji Piper-Beckett, BA Counselling
Emma Peek
Tiria Pehi, Research Fellow
John Penny
Elliott Pepper, Registered Nurse
Andi Pierobon
Nevil Pierse, Professor of Public Health
Jesse Porter
Elizabeth Poucher, Qualified Social Worker
Dr Sarah Prior, FRNZCGP, MBChB, PGDipOMG
Diana Prizgintas, PhD
Lulu Purda, Registered Nurse, PGDip Primary Health Nursing
Nora Purdie, Transgender Healthcare Support Worker
Dr Megan Pybus, MBChB, FRACP
Rochelle Quedley, MCouns, MNZAC
Laura Quin, MSc Psychology - clinical psychology trainee
Cat Railey, Registered Nurse
Dr Sarah Rance, FRNZCGP MBChB
Dr Hemlata Ranga, Psychiatrist MD, FRANZCP
Cerian Rees
Hester Reich, MNZAC - BA Counselling  
Jaime Rendell, MA Psych, PreKure certified Health Coach
Kyrith Reynolds
Annick Richterich, Registered Nurse PgDip
Cayla Robberts 
Ceridwyn Roberts, Science Communicator
Chelsea Robinson, MSc and MSW (app)
Dr Oliver Rooke, Psychiatry Consultant
Dr Amy Rosario, MBBS, FRNZCGP
Lanei Rose, RN, BN
Narnia Rose 
Sally Rose, Senior Research Fellow, PhD
Dr Dane Rua, FRNZCGP, MBChB
Jack Ryan, Medical student
Dr Laura Sandbrook, MBChB
Leslie Sands, Counsellor
Dr David Sar Shalom Abadi, MD, FRNZCGP
Ilana Seager van Dyk, Ph.D, Registered Clinical Psychologist
Avrael Semple
Bianca Sepulveda, BA,BSc,BN, Master of Nursing Science
Miriam Sessa, Registered Child and Adolescent Psychotherapist 
Skye Shaddix
Dr Joanna Sherriff
Andrea Sherrington, Registered Mental Health Nurse
Jennifer Shields, Healthcare Lead & PATHA President
Dr Katie Shillito, FRNZCGP, DCH, DipOMG
Dr Emily Shine, FRNZCGP, PGCertHsc, PGCertWHlth, MBChB
Dr Beth Shore, MBChB, FRNZCGP
Cooper Sides, Youth Worker, Trans Peer Support Worker
Alice Simpson
Nicole Skews-Poole
Joanne Smith, Physiotherapist
Kate Smith, Peer Support Worker
Rachel Smith
Dr Rose Soame, BMBS BMedSci
Dr Wee Ming Soh, MBBS, NZCSRH
Dr Jamie Speeden, MBChB, FRACP (Paeds), FRANZCP (Child & Adol)
Alice Springford-Gough, Child and Adolescent Psychotherapist
Dr Laura Siga Stephan, GP Registrar
Dr Danielle Stefanski, Specialist Physician  MBBS, DTM&H, FRACP
Dr Emily Street, Doctor of Clinical Psychology
Coty Stoddart, Medical Student
Francesca Storey
Professor Maria Stubbe, University of Otago
Dr Nicholas Sullivan, Psychiatry registrar
Vanessa Summers, CBT Therapist - DAPAANZ registered
Kyle Tan, PhD
Ray Tanouye
Amy Taylor, Registered Midwife
Eliza Taylor, Student Nurse
Tayla Taylor, BSW
Dr Victoria Taylor, MBChB, FRNZGCP, PGDipOMG
Claire Teal, Counsellor, NZAC
Sean Tholen, BSc, MTEL
Tina Thompson 
Dr Meg Thomson, MBBS, FRNZCGP
Dr Anneke Thornton, Doctorate in Clinical Psychology
Dr Pleayo Tovaranonte, MBChB, LLM, LLB (Hons), PGDipHlthMgmnt, PGCertCAvMed
Jay Treloggen, Registered Social Worker
Vui Suli Tuitaupe, RN, MHealSc(Nursing), BN, BHSc, Chairperson - Moana Vā, Navigators of Pacific Pride
Karli Tyla
Miles Benjiman Usherwood
Jo Vallance, Clinical Psychologist
Tycho Vandenburg, Researcher
Charlotte Vanhecke
Janell Vaughn, Master of Social Work
Dr Jaimie Veale, PhD, PATHA founding President
Jo Veale
Analosa Veukiso-Ulugia, PhD
E Vokins
Felix Vos-Howett
Dr Alexandra Wallace, BHB, MBChB, DCH, FRACP, PhD
Karen Wakelin, RM, PhD, MA (Applied), BSc (Hons), GDTE
Niamh Walsh, Medical student
Dr Anthony Walters, MBChB, Advanced Trainee in Endocrinology
Rosie Watt
Skyler Watt, Intern Counselling Psychologist
Dr. Robin Watts, Doctor of Clinical Psychology
Slay Way
Elizabeth Weatherly, NZRGON, NZRM, MRNZ
Prof. Ben Wheeler, MBChB, DCH, CCE, PhD, FRACP
Dr Aaron Wiggins, MBBS, BMedSc, MPsych, RANZCP, Cert. Child & Adol Psychiatry
Dawn Willix-Payne, Clinical Psychologist
Katherine Beth Wilson 
Dr Courtenay White, General Practitioner
Dr Rebecca White, Consultant psychiatrist, MBChB, RANZCP
Dr Patricia Whitfield, MBChB, FRACP, PhD
Niamh Winters
Dr Nicole Winters, MSW, PsyD
Cassie Withey-Rila
Sidney Wong, Co-Chair Qtopia, BSc, MLing, MADS
Cameron Wright
Alex Wyn, Registered Social Worker
Rita Yang, Surgeon
Micah Yang
Dr Kwek Suat Yee, General Practitioner
Dr Heather Young, FaChSHM
Jessica Young, PhD
Dr Ji Young Park, MBChB, FRNZCGP
Avery Zavoda, Student Nurse
Lara Zoeller, Registered Nurse 

24 parents of transgender children also signed this letter. We have withheld their names to protect their privacy.

This is PATHA's submission to Manatū Hauora the Ministry of Health's consultation on possible further restrictions to access puberty blockers. This submission has been developed amongst PATHA's Policy & Advocacy and Executive Committees, and draws on the professional expertise of both clinicians and community members amongst PATHA's membership.

Summary of PATHA Recommendations

• Puberty blockers should be prescribed as per international and Aotearoa New Zealand guidelines.

• The process of prescribing or initiating puberty blockers do not require restrictions, given that they are currently prescribed in line with best practice.

• Support, continuing professional development and funding should be provided to enable clinicians to provide accessible care throughout Aotearoa. 

• Restrictions around which clinicians initiate puberty blockers are not required, given that they are currently prescribed in line with best practice.

• Puberty blocker initiation should not be restricted to certain specialties. In Aotearoa, a range of prescribing clinicians should be able to provide this care.

• Clinicians initiating puberty blockers should have an understanding of up to date international best practice and guidelines. Experience working in this area, or support by other experienced clinicians, is important.

• Primary care prescribers with appropriate expertise and support should be able to continue prescribing and initiating puberty blockers in the context of a multidisciplinary team.

• All clinicians initiating puberty blockers should be working as part of an MDT. How this may be configured, and operate, will depend upon which resources and health professionals are available. MDTs may be virtual and may involve correspondence. 

• Access to multidisciplinary team members, including psychologists, counsellors, social workers and peer support workers, should be supported and resourced.

• Any young person with gender incongruence who is seeking puberty blockers and who meets the WPATH Standards of Care 8 criteria should be able to access puberty blockers by having access to an informed consent approach supported by an MDT. Access to puberty blockers should not be further restricted in any way.

• There is currently regional variation in access to puberty blockers. Funding is required to ensure equitable access to puberty blockers around the country.

Read the full submission here.

Manatū Hauora / the Ministry of Health recently published an Evidence Brief and Position Statement on the use of puberty blockers in gender-affirming care

Following PATHA's statement about the Evidence Brief, PATHA leaders have been giving comments to the media. 

Dr Rona Carroll, PATHA Vice-President, General Practitioner, and Senior Lecturer at the University of Otago gave the following comment to the Science Media Centre:

“I welcome the Ministry of Health’s evidence brief and position statement around the use of puberty blockers as part of gender affirming care. All young people deserve access to quality care in which clinicians take a holistic approach which includes their family and whānau, and which offers wider support services when needed. Just as with any other specialty service, this care should be provided by people with expertise, as is already the case in Aotearoa New Zealand.

“Whilst the review did not find high quality evidence of benefits for puberty blockers, it also did not find evidence of harm. However, the evidence accumulated for this position statement focussed entirely on the mental health effects and some specific negative clinical outcomes and doesn’t consider the physical benefits which are the main indication for prescribing puberty blockers in this context.

“Puberty blockers work to prevent potentially unwanted physical changes of puberty, which may result in distress to transgender people. Puberty blockers do not by themselves result in any physical changes; they simply delay the physical effects of puberty that would otherwise occur. The review focussed on identifying evidence to support puberty blockers improving mental wellbeing, but this is not necessarily an expected outcome of the treatment; mental health may not change because the potentially distressing pubertal changes are not happening. It is more important to note the adverse effects on mental wellbeing by not using puberty blockade and therefore experiencing pubertal change, and the position statement does not acknowledge this.

“Furthermore, the review does not take into account the improved outcomes for people beyond adolescence who go on to take gender affirming hormone therapy. In my experience, individuals who have used puberty blockers are more likely to see the physical changes they would like to see in adulthood from sex hormone therapy, as irreversible physical changes that occur during puberty are not present. It is at these later stages where we see the clinical benefits. Every week in my GP clinic I hear from young people and adults with gender incongruence who did not have puberty blockers, and who now suffer and struggle in ways which have a huge impact on their day-to-day life, due to the physical changes which occurred during puberty. There is little published data on this as an outcome, but it remains a primary indication for the use of puberty blockade.

“Another consideration of the narrow focus of this review is that it only reviewed evidence in relation to these medications in the context of gender affirming care. The same medications used to achieve puberty blockade in this context are widely used in other areas of healthcare such as precocious puberty and menstrual disorders. There is no evidence for sustained adverse effects from this in these areas, but this is not considered in the statement.

“When considering the balance of the potential benefits and low level of identified risks, limiting or restricting access to puberty blockers would not be an ethical approach to take. I fully support the need for high quality longitudinal data in this area, alongside continued access to holistic and interprofessional care for young people seeking gender affirming healthcare.”

Dr Carroll also gave the following comment to The Post:

"The ministry’s advice just cemented the need for a best practice approach ‒ which should have already been happening.

“Clinicians already exercise caution. They understand it's a complex area. They work in teams. They really provide that time and support to make sure it's the right thing for people.

“They're actually quite difficult to access. There’s a really long waiting list to get into these services, and they're being prescribed by people who have expertise in the area.

"Any moves to restrict or block access to puberty blockers would almost definitely cause harm”

 Jennifer Shields, PATHA President, gave the following comment to RNZ:

"The evidence brief has only been out 24 hours and I've already had a number of families message me quite distressed, concerned for the wellbeing of their young people, concerned about their ability to access healthcare in the future.

"Any further restrictions are unnecessary and would only do harm to those who need that care the most

"PATHA is concerned about the appropriateness of opening this consultation on a medical matter to the wider public particularly when the matter of gender affirming care has become highly politicised and subject to disinformation.

"I would really caution the Ministry of Health to take that into consideration when they are assessing the findings of that consultation and really would caution government in particular about the impacts that a public consultation process is likely to have on the health and wellbeing of trans people of all ages but particularly for trans young people."

"It is important to take the politics out of a healthcare matter and bring it back to the wellbeing of the young people.  At the centre of this there are children and young people who are experiencing mental distress, who are navigating a journey of gender recognition, who really do need access to this care and I would encourage people to think about what that experience is like.

"To even have questions about your identity and whether the body you have is the right one for you and to be experiencing potential permanent changes to your body that you have no control over, knowing that there is an intervention out there that can give you the time to make a decision without those permanent changes looming over you and then to have that option taken away is really traumatic for a lot of people.

"A lack of high quality evidence is not unique to puberty blockers. When we're thinking about high quality evidence, quite often we're talking about randomised control trials and those are really difficult and challenging to undergo for gender affirming care particularly. Partly because of the ethical considerations around withholding necessary care but also because if you're giving one group a placebo and another group puberty blockers or hormone therapy it becomes pretty obvious pretty quickly who's on what.

"I think it's really important that we're not holding this kind of healthcare to a standard that healthcare for the general public doesn't meet.

"Best practice often looks like paediatricians working alongside mental health professionals, peer support and social workers to help a young person and their family make the choices that are best and right for them, with the support they need. If the government is concerned about the safety of gender diverse young people, it is important to make sure clinicians nationally are adequately resourced and have access to this multidisciplinary support. PATHA would like to see standardised access to care and investment from the ministry for this.

"There may be limitations to comparing a New Zealand context to that of other countries. Particularly around the model and approach we take here in Aotearoa, some of the biggest comparisons that are often drawn are with healthcare provision in England, in the UK, and their approach to gender care, for a very long time, has been a centralised clinic model, which has meant long wait times and lower rates of access. Care in New Zealand is provided locally with every region having a distinct pathway, something which has a tangible impact of those accessing care.

"The Ministry's position statement makes it clear that puberty blockers can continue to be used as part of a comprehensive care plan for trans and gender diverse young people where needed.  The statement is not a new set of rules, but guidance that acknowledged the approach experts already use.

"PATHA will continue to work to ensure access to this important care is maintained."

PATHA responds to a recent NZMJ article regarding prescribing rates for puberty blockers in Aotearoa New Zealand

The NZMJ article compared New Zealand's prescribing rates with those England, Wales, and the Netherlands.

GP Dr Rona Carroll from PATHA's Executive Committee states:

Puberty blockers can have a positive effect on the mental health and wellbeing of transgender and gender diverse young people. In New Zealand, children and young people access puberty blockers through a careful assessment and support process that includes a team of healthcare professionals and psychological input.

New Zealand is a progressive country which recognises the importance of accessibility to healthcare and support for gender diverse young people. Our model of care is different from the centralised gender clinic model used in the comparison countries in this paper. These centralised clinics overseas have often led to excessively long wait times for care.

For these reasons, it is not surprising that New Zealand has higher rates of prescribing puberty blockers. As the authors point out, the number of transgender young people does not appear to be increasing. Instead, the higher prescribing rates may be because young people feel safe expressing their gender and healthcare needs, have access to appropriate health services and live in a country where inclusion and respect for transgender individuals is growing. It is a good sign that young people are feeling comfortable to discuss their gender with their whānau and express their needs.

Using data from UK gender clinics might not accurately reflect the true need for puberty blockers in the UK, where accessing this care can be extremely difficult. Our goal should not be to match UK prescribing rates, but rather to ensure that gender diverse children and young people receive accessible, individualised, and holistic care. The PHARMAC data presented in the paper suggests that New Zealand is responding to this need.

- 27 September 2024

Further responses are available here.

PATHA will be holding its 2024 Annual General Meeting via Zoom at 2pm on Saturday 24 August 2024. This is expected to run for approximately one hour.

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 - Welcome to new Policy and Advocacy Committee members, and thank you to outgoing Policy and Advocacy Committee members.
8. Close meeting

PATHA members can log in to find the Zoom link for the online AGM, copies of the reports, and information about nominees received for the Executive Committee. Some of this information is already available to members upon logging in, other information will be uploaded to the same page closer to the date of the AGM.

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.

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.

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/

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.

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

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.

Below is the briefing that PATHA sent to the incoming (2020) Minister of Health on the topic of transgender health. We have made this public as they might be useful for anybody advocating to advance transgender people's health.

We thank the PATHA Policy and Advocacy Committee for their expertise and work that they did to create this.

You can use this link to download the briefing document.

Annual General Meeting for the Professional Association for Transgender Health Aotearoa (PATHA)

June 20 2020

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. Executive Committee recommended motions to amend PATHA rules: 

   1. Section 4.2: Increase number of General Executive Committee Members from 3 to between 3 and 5.

   2. Section 4.5: Amend the following sentence to include “between Māori and non-Māori people” as highlighted below: 
      “The mix of Officers and Executive Committee members should demonstrate a partnership between cisgender and transgender people, and between Māori and non-Māori people, working professionally on transgender health, whether in clinical, academic, community, legal or other settings.”

   3. Section 8.1: The role of the Executive Committee. Amended to include the following highlighted sentence: “Ensure that transgender Members are represented in any decisions made.”

   4. Section 10.2: Amend this to include “and transgender members are represented in decision making” as highlighted below: 
      “No Executive Committee Meeting may be held unless more than half of the Executive Committee Members attend and transgender members are represented in decision making.”

7. Election of Executive Committee Members 
8. Close meeting

PATHA asserts that the provision of gender affirming healthcare for transgender and gender diverse people is a medical necessity and that the lack of equitable access to this healthcare in Aotearoa is causing harm.[1]

PATHA notes that in He Ara Oranga (The Report of the Government Inquiry into Mental Health and Addiction) rainbow populations are recognised as being negatively impacted by “the cumulative effects of discrimination, bullying, prejudice and exclusion,” and that in addition limited access to gender affirming healthcare “has a negative effect on the mental health and wellbeing of people seeking to access them (p72).[2] 

It is the opinion of PATHA that limited and inconsistent access to essential healthcare (such as puberty blockers, fertility preservation, gender affirming hormones, mental health support and gender affirming surgeries including chest reconstruction, hysterectomy and orchiectomy) is itself an aspect of discrimination. 

PATHA recognises the right of transgender and gender diverse people to be able to make informed choices for themselves regarding gender affirming healthcare and that as a minimum, District Health Boards (DHBs) should provide timely access to the following services: puberty blockers, fertility preservation, gender affirming hormones, mental health support and gender affirming surgeries including chest reconstruction, hysterectomy and orchiectomy.

Currently, there are large variations in the provision of gender affirming healthcare services across the 20 DHBs in Aotearoa, New Zealand.[3] PATHA strongly recommends that all DHBs provide clear information about pathways to access gender affirming healthcare services delivered by DHBs and primary health care. PATHA recognises that these healthcare services should involve transgender people, including Māori transgender people, in the development and provision of services.[4] 

PATHA affirms that all health services in New Zealand must provide equitable and accessible gender affirming healthcare services that are evidence based and align with international standards and community feedback. To that end, PATHA recommends that DHBs enable flexible and responsive pathways that are based on informed consent and self-determination.[4]

References

[1] For a list of medication organisations who affirm the medical necessity of gender affirming care see: https://transcendlegal.org/medical-organization-statements. For more information about the health of transgender people in New Zealand and the negative impact of inconsistent access to gender affirming healthcare see Veale J, Byrne J, Tan K, Guy S, Yee A, Nopera T & Bentham R (2019) Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Transgender Health Research Lab, University of Waikato: Hamilton NZ. https://countingourselves.nz/index.php/community-report/.

[2] See the full report here: https://www.mentalhealth.inquiry.govt.nz/inquiry-report/he-ara-oranga/

[3] For more details on the lack of consistent gender affirming services across New Zealand see: https://patha.nz/news/is-the-provision-of-gender-affirming-health-care-equitable-across-the-district-health-boards-in-aotearoa-new-zealand

[4] Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, Stephenson C, Bullock J. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato, 2018, p8-9. https://researchcommons.waikato.ac.nz/handle/10289/12160