November 7, 2021

First Mental Health Guideline to Explicitly Deviate from Gender Affirmation

Australia and New Zealand College of Psychiatrists recognizes that gender dysphoria can arise from multiple causes

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) released its first position statement addressing the mental health needs of people with Gender Dysphoria/Gender Incongruence in August 2021, which was followed by an update in September 2021. Prior to this, the college’s position in relation to Gender Dysphoria was contained within the position statement on LGBTQ mental health. This new statement is the first position statement released by a professional body, as far as we are aware, which does not specifically endorse a gender-affirming approach.

According to the RANZCP's website, the following are the key messages contained in the new position statement

Key messages

  • Gender Dysphoria is associated with significant distress.
  • There are polarized views and mixed evidence regarding treatment options for people presenting with gender identity concerns, especially children and young people. It is important to understand the different factors, complexities, theories, and research relating to Gender Dysphoria.
  • It is important that there is adequate, person-centered care, for the mental health needs of people experiencing Gender Dysphoria.
  • Psychiatrists play a crucial role in caring for the mental health needs of people experiencing Gender Dysphoria.
  • Psychiatrists should act in a manner which is supportive, ethical, and non-judgmental.
  • 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.
  • Psychiatrists must have regard to the relevant laws and professional standards in relation to assessing capacity and obtaining consent, including the RANZCP Code of Ethics.
  • Gender Dysphoria is an emerging field of research and, at present, there is a paucity of evidence. Better evidence in relation to outcomes, especially for children and adolescents is required.

 

SEGM Analysis

The position statement is notable for its reserved and cautious tone when describing gender-affirming treatments for young people. It does not present gender-affirming treatments as the gold standard approach, citing “polarised views and mixed evidence regarding treatment options for people presenting with gender identity concerns, especially children and young people.” The statement notes that “professional opinion is divided as to whether an affirmative approach should be taken in relation to the treatment of transgender children or whether other approaches are more appropriate.” The College advises psychiatrists to be aware of the multiple perspectives and views about the best way to respond to gender dysphoria.

The gender-affirming approach is presented as one approach that clinicians can take. Psychotherapy offers an alternative that does not entail medical treatment. Both approaches are presented as equally valid, however the College warns that there is a paucity of quality outcome research to inform treatment decisions. They highlight the need for better outcome data especially for children and young people.

The statement highlights the important role psychiatrists have in performing a comprehensive assessment. In particular, the statement notes that gender dysphoria arises in a context and this must be carefully explored to best address the mental health needs of the individual. While not explicitly stated by the RANZCP, an emphasis on the the context in which Gender Dysphoria/Gender Incongruence arise is consistent with a developmental view of gender dysphoria as an emergent phenomenon shaped by many influences. This contrasts with other views of gender identity which view it as an innate and fixed essence.

In its previous LGBTQ position statement, the RANZCP recommended that clinicians administering pubertal blockade follow the Royal Children’s Hospital (RHC) Melbourne Guidelines. This particular recommendation no longer appears in the new position statement, with the RCH guidelines now listed as one of a number if guidelines that clinicians should be aware of. The College emphasizes that it does not preference any specific guidelines. This appears to represent a change in the College’s position to one which is much more circumspect about the RCH guidelines.

The other notable aspect of this statement is that it alerts clinicians to the potential medico-legal implications of treatment for gender dysphoria, advising Fellows to practice within the relevant laws within their jurisdiction. It also raises the important issue of informed consent, emphasizing that patients and their families must be provided with sufficient information.

Concluding Thoughts

SEGM welcomes RANZCP's nuanced and thoughtful guidance for mental health professionals caring for the rapidly growing numbers of gender-dysphoric youth. The RANZP highlights the unknown long-term outcomes of invasive hormonal and surgical treatments. This is especially relevant for young people, who will be impacted by the effects of these largely irreversible interventions for decades to come.

SEGM also applauds RANZCP's acknowledgement that the state of the evidence regarding medical interventions for gender dysphoria is poor, and an agreed-upon standard of care does not exist. The deficiencies in the evidence base have recently been highlighted by the NICE systematic reviews of evidence. To meaningfully consent to endocrine and surgical gender-affirmative interventions, patients and families must be made aware of the widespread methodological problems in the outcome research, and the lack of certainty that these interventions will, on balance, be more beneficial than harmful. Until high quality evidence is available to ascertain who will benefit and who might be harmed by "affirming" endocrine and surgical interventions, exploratory psychotherapy should be the first-line treatment for young people suffering from gender-related distress.