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

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.

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 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.

The 2021 PATHA Annual General Meeting will be held via online video call from 1-3pm on Saturday the 19th of June, 2021. At this meeting, we will be electing members to the positions of President, Vice-President, Secretary and up to four general Executive Committee members. We are seeking nominations for these positions. All of these positions are voluntary and unpaid.

Background

PATHA is an interdisciplinary professional organisation that works to promote the health, wellbeing, and rights of transgender people. We are a group of people working professionally on transgender health in clinical, academic, community, legal, and other settings. We envision an Aotearoa New Zealand where all transgender people have full access to appropriate healthcare, and that all healthcare providers have access to information and resources which enable them to provide appropriate healthcare. You can read PATHA’s full vision and purposes here.

At present, PATHA is run entirely by volunteers and governed by an Executive Committee. Some of PATHA’s work is undertaken by committees - the Policy and Advocacy Committee and Education Committee - that have active participation by non-Executive Committee members. 

The PATHA Executive Committee has a friendly and collaborative atmosphere and is made up of a diverse group of transgender and cisgender people with a shared passion for transgender health. We have a range of professional and volunteer affiliations and experience working in relevant fields. We aim to have an Executive Committee that is ethnically, geographically, and professionally diverse. PATHA strives to uphold the principles of the Treaty of Waitangi. 

Responsibilities

PATHA Executive Committee members are expected to:

• participate in Executive Committee meetings;
• actively contribute to working towards of PATHA’s vision and purposes;
• complete action items between meetings; and
• be able to commit to an average of two to three hours of work per week.

During meetings, each Executive Committee member is expected to:

• be prepared and have read background information sent to Executive Committee members about the issues being discussed;
• actively participate in the meeting;
• interact with fellow Executive Committee members in a respectful and constructive manner; and
• take responsibility for completing specific action items.

In addition, the President, Vice-President and Secretary have the following responsibilities:

President
The President is responsible for: overseeing PATHA’s operation and ensuring its Rules are followed, convening and chairing meetings including the Annual General Meeting, and providing a report on PATHA’s operations at each Annual General Meeting.

Vice-President
The Vice-President is responsible for: assisting the President with their responsibilities, including stepping into the role of the President and chairing meetings in the event of the President being absent or unable to fulfil their duties.

Secretary
The Secretary is responsible for: recording the minutes of meetings; overseeing the register of members; maintaining PATHA’s records and documents; and receiving and replying to correspondence.

Commitment

The PATHA Executive Committee holds monthly meetings via videoconference. These meetings typically last 90 minutes and are held on weekday evenings. Executive Committee members are expected to attend meetings regularly. Executive Committee members are also expected to actively contribute to the achievement of PATHA’s vision and purposes by completing specific activities in their own time.

Eligibility

You must be a PATHA member to apply for these positions.

We encourage people with the following skills and experiences to stand for these positions:

• Have a demonstrated commitment to, and knowledge of, transgender health and healthcare
• Have knowledge of Māori and Pasifika models of transgender health
• Possess a collaborative, collegial working style
• Have strong communication skills
• Be well connected with with transgender communities and/or health providers working with transgender communities
• Have a strong understanding of the breadth of factors that influence transgender people’s health and well-being, and of diversity within transgender communities

A range of skills are necessary to ensure a smoothly functioning Executive Committee. These include: legal skills, accounting / finance skills, fundraising, media relations and communications strategy, and knowledge of regulations governing incorporated societies.

PATHA’s rules require that the mix of Officers and Executive Committee members should demonstrate a partnership between cisgender and transgender people, and between Māori and non-Māori, working professionally on transgender health, whether in clinical, academic, community, legal or other settings. We aim to have an Executive Committee that is ethnically, geographically, and professionally diverse. As part of our desire for geographical diversity, we are particularly interested in nominations from people living in the South Island, and as part of our desire for professional diversity, we are particularly interested in nominations from people with primary care experience.

Term

Executive Committee term lengths are two years. 

How to Apply

To nominate yourself for one or more of these positions, please fill out the online form here by 5pm, Monday June 14th.

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 their expertise and work that they did to create these.

You can also use this link to download the briefing document.

We are pleased to announce that this symposium will be held at Tautoru TSB Space, Tūranga Central Library, Ōtautahi Christchurch on 25-26 September 2021. Click here for more information about this symposium.

WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, and PATHA Response to Bell v. Tavistock Judgment

[Update 5/4/2021: This statement has been developed into a paper that was published in the International Journal of Transgender Health. It is available on the WPATH website here. The authors note “the current paper is an extended version of that statement including the scientific evidence and references which the necessary brevity of such policy statements precludes”.]

[Update 1/1/2021: AusPATH have also released their own statement about this ruling which is available here.]

Statement Regarding Medical Affirming Treatment, Including Puberty Blockers for Transgender Adolescents

The Boards of Directors of the World Professional Association for Transgender Health (WPATH), the European Association for Transgender Health (EPATH), the United States Professional Association for Transgender health (USPATH), the Asia Professional Association for Transgender Health (AsiaPATH), the Canadian Association for Transgender Health (CPATH), the Australian Professional Association for Trans Health (AusPATH), and the Professional Association for Transgender Health Aotearoa (PATHA) all strongly disagree with the recent judgement of the London High Court in Bell v. Tavistock. We believe this decision will result in significant harm to the affected children and their families. We oppose this ruling and urge that this ruling be appealed and overturned.

Click here for the full statement.

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