What next? RANZCP statement on gender dysphoria conflicts with AusPATh

Analysis by Simon Tegg, who is part of Fully Informed, a group of people from across New Zealand concerned about the legality and long-term impacts of prescribing puberty blockers to children.

The Royal Australia New Zealand College of Psychiatrists (RANZCP) is the registration body for psychiatrists in the two countries. In September 2021, the RANZCP released a position statement: “Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence.” 

The statement attempts to stake out a middle ground between “polarised views” and protecting members from liabilities that could arise in rapidly developing and diverging legal contexts. However, professional views on the appropriate treatment for children and young people with gender dysphoria (GD) are now so polarised that the RANZCP’s ‘middle ground’ position inevitably conflicts with recommendations made elsewhere. 

This article compares sections of the RANZCP statement with conflicting sections of commonly used guidelines in Australia and New Zealand. In Australia, the RANZCP statement is contrasted with guidelines published by the Royal Children’s Hospital Melbourne and endorsed by the Australian Professional Association for Trans Health (AusPATH). In New Zealand, the comparison is with guidelines published by the Transgender Health Research Lab at the University of Waikato and endorsed by AusPATH’s sister organisation, the Professional Association of Transgender Health Aotearoa (PATHA). For simplicity, the guidelines are referred to as the “AusPATH Guidelines” and the “PATHA Guidelines,” respectively.

Conflicting professional opinions speak to the urgent need for regulation.

-Simon Tegg

Evidence

RANZCP:


“Research on Gender Dysphoria is still emerging. At present, there is a paucity of quality evidence on the outcomes of those presenting with Gender Dysphoria. In particular, there is a need for better evidence in relation to outcomes for children and young people.”

AusPATH Guidelines:

“Increasing evidence demonstrates that with supportive, gender affirming care during childhood and adolescence, harms can be ameliorated and mental health and wellbeing outcomes can be significantly improved.” (p. 2)

The statement is a close copy of one found in the PATHA Guidelines:

“However, increasing evidence demonstrates that supportive, gender affirming care for trans people significantly improves gender dysphoria and mental health and wellbeing outcomes.” (p. 21)

Indeed, three authors of the PATHA Guidelines, Mo Harte, Dr Jaimie Veale, and Dr Rachel Johnson, are acknowledged by the AusPATH authors. The PATHA Guidelines also repeats a version of the statement in a section on easing the concerns family members may have regarding puberty blockers:

“There is good evidence that puberty blocking and gender affirming care for trans young people significantly improves mental health and wellbeing outcomes.”

Well, which is it? Is there a “paucity of quality evidence,, or is there “good” and “increasing” evidence? It cannot be both, and clinicians will have to assess the evidence themselves or decide who they trust more, the RANZCP or AusPATH/PATHA.

The contradiction raises broader questions on what counts as ‘quality evidence’ and ‘quality guidelines.’ Authors of evidence-based clinical guidelines systematically review and grade evidence, linking the strength of a specific intervention recommendation to the strength of the evidence supporting that intervention.¹ Neither the AusPATH nor PATHA guidelines follow systematic, evidence-based methods, but the casual reader will not know this and may assume that all clinical guidelines have a similar degree of rigour. 

Instead, for the AusPATH Guidelines, “[r]ecommendations are made based on available empirical evidence and clinician consensus.” (p. 2). Publishing the existing practices of a group of like-minded clinicians as ‘consensus guidelines’ with recommendations linked to a few studies lets AusPATH take advantage of the casual reader’s lack of familiarity while cosying up to the ‘evidence-based brand.²

For example, both AusPATH and PATHA guidelines deploy the term “gender affirming care” to collapse non-invasive (but still consequential) interventions such as social transition together with arguably experimental pharmaceutical interventions such as puberty blockers and cross-sex hormones (CSH). In this way the authors can pad out the citations for the combined ‘gender affirming’ approach, propping up the subset of controversial claims by association with the better-supported claims. The technique will be familiar to anyone with an undergraduate degree who was still writing at term paper at 2 am on the due date.

The AusPATH statement cites four references for the “increasing evidence” for “gender affirming care.” One of the references is a broad discussion of the gender-affirming model.³ Two of the references are on the supposed benefits of social transition.𝄒 The fourth is an uncontrolled study of mental health benefits of puberty blockers where subjects made marginal improvements that could be attributed to the placebo effect (and in which one subject later died following surgical complications).

The benefits of social transition (the use of opposite-sex pronouns and stereotypical manner of dress) are also suspect. Sievert et al. (2021) split out social transition from the confounding effect of general social support of peers and family for gender dysphoric children. They found no benefit from social transition: 

“ …claims that gender affirmation through transitioning socially is beneficial for children with [gender dysphoria] could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.”

Assessment

RANZCP: 

Comprehensive assessment is crucial. Assessment and treatment should be evidence-informed, fully explore the patient’s gender identity, the context in which this has arisen, other features of mental illness and a thorough assessment of personal and family history. This should lead to a formulation. The assessment will be always responsive to and supportive of the person’s needs.”

Following the RANZCP advice, the psychiatrist makes a “formulation” after a comprehensive assessment. The statement avoids details but in the case of a child or young person, the formulation is going to have to include judgement on whether the patient should proceed to puberty suppression or CSH. The “evidence-informed” psychiatrist may note that hormone treatments do not have high-quality evidence. In some cases, the psychiatrist may note that the ‘context in which the gender identity has arisen’ includes co-morbid mental health problems and troubled family history. In short, the RANZCP statement allows psychiatrists to pass judgement on a patient’s needs and contradict a child’s or parent’s desires for bodily modification by recommending psychosocial support and/or antidepressants. This is presumably the standard practice that psychiatrists follow for any other condition, and it is remarkable that the RANZCP feels the need to restate it here.

PATHA Guidelines: 

“Include mental health issues as part of a holistic psychosocial assessment, for example discussion of anxiety, depression, risk of self-harm, while being clear that having mental health issues is not a barrier to accessing gender affirming services.

Respect the self-determination of each person as being the expert on their experience. This is often referred to as the “informed consent model” of gender affirming healthcare because it counteracts pathologisation and repositions the transgender person as being at the centre of their own life. (p.22)

In contrast, a clinician following the PATHA Guidelines must not contradict the patient. The patient will ‘self-determine’ their own treatment, and the clinician’s role is to facilitate and legitimise access. It is heavily implied that a mental health diagnosis would be ‘pathologising’ and harm the patient by contradicting their self-conceptions. Stripping away the euphemisms, PATHA propose that a child who is mentally unwell enough to be at a high risk of self-harm should decide if puberty blockers and cross-sex hormones are the right choices.

Legal issues

AusPATH: 

“Legal advice may be sought…in the case of an objecting parent or legal guardian who initiates legal proceedings with the aim of preventing commencement or continuation of treatment.” (p. 22)

PATHA: 

“Discussion regarding privacy of health information and the limits of confidentiality is important in every consultation with a young person. Young people need to understand that their concerns and information will be kept private and confidential within the limits around their own and others safety.”

“Decisions regarding medical interventions are ideally made collaboratively between the trans young person, their whānau and the health team. However, it is not always possible to involve family. Lack of whānau support does not preclude trans young people from accessing care. While young people aged 16 years and older are considered to be able to make decisions about their medical care…younger people are not prohibited from consenting to medical interventions if the young person is deemed to be competent to make an informed choice. To assist this informed consent process, we recommend that gender affirming healthcare for young people is provided within a multi-disciplinary team.” (p. 17)

Both PATHA and AusPATH agree that treatment can proceed without full parental consent. PATHA advises keeping the parents in the dark. Patients under 16 can be ‘deemed competent,’ although whether they actually are competent is another matter. AusPATH’s advice to call a lawyer and challenge an objecting parent in court betrays a blunter, more combative, daresay more stereotypically Australian approach when compared to the ‘collaboration’ suggested by Kiwis.

Since publication, an Australian court has ruled that a court order is mandatory when a parent objects. AusPATH’s advice is now out of date, since the objecting parent will no longer have to initiate legal proceedings.

With the benefit of an extra year of court judgements and law changes relating to conversion therapy, RANZCP advises psychiatrists to avoid cases that could end up in court and take actions to mitigate that possibility: 

“Health professionals should also be aware of ethical and medicolegal dilemmas in relation to medical and surgical treatment for people experiencing Gender Dysphoria…Given the complexity of these issues, it is essential that sufficient information is provided to people…to enable informed consent. Further, evidence for clinical decisions about whether a child or adolescent is capable and competent to consent to treatment should be clearly recorded.”

Conclusion

Conflicting professional opinions speak to the urgent need for regulation. In one Australian state, clinicians must seek court approval before prescribing hormone treatments. At the same time, a state Supreme court has heard a case brought by parents who lost custody after they refused consent for the child’s hormone treatments. An unsuspecting parent might receive advice to initiate puberty suppression and hormone treatments or might receive advice to initiate psychotherapy depending on the personal beliefs of the clinician consulted and their professional memberships.

The RANZCP (established 1946, 7000 members in 2020) is an older, larger, and more mature organisation than either AusPATH (predecessor ANZPATH established 2009, 200 members in 2018) or PATHA (established 2019 with 15 members). It is not surprising that they take a more cautious approach. 

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