Advocacy

AusPATH STATEMENT ON MEDICAL GENDER AFFIRMATION AND RE IMOGEN

The Australian Professional Association for Trans Health (AusPATH) was established in 2009 and is Australia’s peak body for professionals involved in the health, rights and well-being of all trans people, including those who are gender diverse and non-binary. The AusPATH membership comprises approximately 250 experienced professionals working across Australia.

We wish to first and foremost congratulate Imogen that she can now proceed with her own wishes to medically affirm her gender. AusPATH cares deeply for your wellbeing and gender euphoria. We affirm your gender, your trans experience and value the immense contribution you have made to the health and rights of trans and gender diverse people in Australia. Thank you.

Background to Re Imogen

 Over the course of the last eight years, the Family Court of Australia has made a number of judgments related to the treatment, care and agency of trans and gender diverse young people. First, the ruling of Re Jamie (2013) overturned existing law that required an adolescent and their family to go to The Family Court of Australia to gain authority to commence puberty blockers prior to 18, provided the parents and the young person’s medical practitioner were in agreement.

The second ruling, Re Kelvin (2017) enabled young people to commence gender affirming hormones prior to age 18 without Family Court authorisation. In this case, the Court did not comment on how a young person seeking to access gender affirming hormones may do so if their parents were in dispute about the matter.

The effect of this was that gender affirming hormonal treatment (‘Stage 2’) was deemed therapeutic and treatment for which consent no longer lay outside the bounds of parental authority (nor required the Court’s approval, reversing the position in Re Jamie). Re Kelvin also determined that, in respect of hormonal treatment, if the child, the parents and the medical practitioners agree a child is Gillick competent, there was no need for the Court to determine Gillick competence (reversing the position in Re Jamie).

Finally, Re Kelvin is authority for the rule that if all parents and medical practitioners agree, a Gillick-competent child can consent to gender affirming hormonal treatment, and, if a child is not Gillick-competent and the treating medical practitioners agree, the child’s parents can consent to commencing hormonal treatment without court approval.

This ruling was further clarified in this judgment of Re Imogen (2020) to mean that, in Australia,  young people can only receive hormone treatment when there is no dispute between parents (or those with parental responsibility), the medical practitioner and the young person themselves with regard to:

  • the young person’s Gillick-competence; or
  • a diagnosis of Gender Dysphoria; or
  • proposed treatment for Gender Dysphoria.

Any dispute requires a mandatory application to the Family Court.

We note that the Court:

took the view that Imogen, the young person in this case:

satisfies the criteria for the DSM-5 diagnosis of Gender Dysphoria (satisfying both criteria – gender incongruence and associated distress) (182), and this diagnosis was not precluded or otherwise undermined by presence of other mental health issues (176, 182);

is Gillick competent (199); and

should continue to receive gender affirming treatment, moving on in her case to gender affirming hormones (‘Stage 2’) (231);

We note further that the Court:

found that there was no evidence that she had “been infected by contagion as a result of involvement with the internet or social media” (197); and

was troubled by Imogen’s self-medication, seeing it as evidence of the ‘dangers that have been created by the dispute in this case’ (208).

We are pleased that the Court:

recognised that the gender affirming model of healthcare is the consensus medical approach in cases of Gender Dysphoria (224);

accepted as a ‘risky and unproven strategy’, both in this case and as a broader approach for treatment, the psychotherapeutic approach offered as an exclusive alternative that would delay medical gender affirmation for up to 12 months (226);

rejected that it would be in Imogen’s best interests for an order to be made requiring her to undergo psychotherapy (239) and determined that a medical gender affirming approach to initiate gender affirming hormones (‘Stage 2’) was the correct one for Imogen (231);

listened carefully to Imogen’s own wishes (205, 207) regarding treatment, as well as the views of the healthcare providers who best knew her and her circumstances;

at various points throughout the judgment, explicitly recognised the best interests of the trans young person as the ‘paramount consideration’ (e.g. 35, 44);

clarified that the informed consent and approval letter protocols are lawful models of gender affirming healthcare by stating that ‘absent any dispute by the child, the parents and the medical practitioner, it is a matter of the medical professional bodies to regulate what standards should apply to medical treatment’ (63); and

displayed throughout a capacity to appreciate the complexities of research into gender affirming healthcare and trans health more broadly, including about suicidality (155) and that lost-to-follow up figures cannot be interpreted as proof of affirmation regret in follow up studies (158, 159).

We are, however, disturbed that the Court has:

clarified Re Kelvin and Re Jamie, that any young person under 18, diagnosed by their medical practitioners as having Gender Dysphoria, assessed as Gillick competent, and desiring medical gender affirming treatment, but whose parents are in dispute about the proposed treatment, the Gillick competence of the child and/or the diagnosis, is required to make an application to the Family Court of Australia to access gender affirming treatment; and

that medical practitioners seeing Gillick-competent patients under the age of 18 are unable to initiate puberty blockers or gender affirming hormonal treatment ‘without first ascertaining whether a child’s parents or legal guardians consent to the proposed treatment’ (63).

In view of the above, AusPATH believes that the judgement contradicts the principle that the child’s best interests are paramount.

Therefore, AusPATH asserts that this judgement:

will cause distress across the trans community, to families with trans children, and to the medical professionals and teams providing care to young people seeking such medically necessary care;

means that many trans young people will face uncertainty and delays to medically necessary treatment, and their families will face significant or prohibitive costs and, in the cases of an absent or unsupportive parent, a time-consuming court process; and

places an additional burden on medical practitioners providing gender affirming healthcare by requiring additional, often complex, processes with families and by being forced to advocate in court for their patients.

AusPATH further asserts that:

access to timely, culturally-safe and person-centred gender affirming healthcare is critical to protect trans children, adolescents and adults from negative health and wellbeing implications. Delaying treatment for any trans person – but particularly a trans young person – can lead to increased risks of anxiety, depression, self-harm and suicidality;

young people of sufficient maturity should be allowed to provide informed consent to their own treatment, in partnership with their treating medical practitioners, without being put to the expense, delay, public profile and undermined privacy involved in court authorisation when parents are in dispute;

in many cases where parents, carers or guardians are in dispute, this judgement will result in a trans person waiting until they are 18 to access hormones, or, as in Re Imogen, purchase hormones without medical monitoring (111); and

the medical care needs of trans young people should be treated with the consistency of the medical care provided for other health issues along with previous judgements made that centre and listen to the voice, agency and capability of the young person themselves.

AusPATH looks forward to resolutions in the law that advance and protect the best interests, rights and health of trans young people in Australia, and make it possible for the medical practitioners to provide the medically necessary gender affirming treatment and care.

Finally, AusPATH calls for the Australian Parliament to consider amending the Family Law Act 1975 (Cth) to give effect to correcting the judgment of Re Imogen so that trans young people are not adversely affected by the judgment.

AusPATH Board of Directors

AusPATH Policy Committee

AusPATH gratefully acknowledges the pro bono legal counsel provided by Nicholas Stewart of Dowson Turco Lawyers.

21 September 2020

AusPATH STATEMENT ON BLACK LIVES MATTER

The Australian Professional Association for Trans Health (AusPATH), established in 2009, is Australia’s peak body for professionals involved in the health, rights and wellbeing of trans people, including those who are binary, non-binary and gender diverse. The AusPATH membership comprises approximately 300 experienced professionals working across Australia.

AusPATH stands in solidarity with advocates across Australia, and around the world, fighting against anti-Bla(c)k racism, of which those who are trans and also First Nations, Blak or people of colour are disproportionately affected and most impacted, globally. We see this particularly among our trans sisters.

Racism is not an issue confined to the United States. It is a systemic and pervasive problem in Australia that continues to cause harm to the health and wellbeing of trans people of colour and First Nations trans people. The impacts of colonisation in Australia have created inequities that leave Sistergirls, Brotherboys, other trans Aboriginal and Torres Strait Islanders and trans people of colour more vulnerable to discrimination and stigma within healthcare settings, in public, on the street, at home, at work, at school and across the lifespan. This must end.

We know all too well that trans people in Australia shoulder some of the heaviest burdens of poor health and wellbeing. The communities AusPATH serves report highly disproportionate experiences of emotional, financial, physical and sexual violence, disproportionate rates of social isolation, rejection, unemployment, distress, self-harm, substance use and suicidality. We also know that trans people in Australia experience barriers to medical and mental health care. Racism further compounds these experiences for trans people who are First Nations, Blak or people of colour.

Racism and transphobia are key social determinants to ill-health, reduced quality of life and mortality; transphobic racism is bad for our communities’ health.

In recent weeks, our social media and television screens have made the disproportionate policing, criminalisation and incarceration of First Nations, Black and people of colour all the more visible. However, racism has long been entrenched in our education, healthcare, political and legal systems. Even today, trans women, trans men, and non-binary people in Australia, many of whom are Sistergirls and Brotherboys, are held in prisons that do not reflect their gender.

AusPATH will continue to focus our communication platforms on promoting and amplifying trans First Nations voices and the voices of trans people of colour in Australia. The Board of Directors commits to facilitating ongoing education and dialogue within our own organisation and membership and we make a commitment to actively seeking increased representation from trans First Nations people and trans people of colour on the AusPATH Board.

AusPATH calls for Federal, State and Territory governments and policymakers to urgently partner with community-controlled organisations to address the systemic racism and transphobia that contributes to the ill-health of trans First Nations people. AusPATH encourages healthcare providers and the medical community to challenge personal beliefs about race and gender so that the highest attainable level of health can be accessed by all trans people in Australia.

All Bla(c)k Lives Matter. Bla(c)k Trans Lives Matter.

AusPATH Board of Directors and Policy Committee

Thank you to the Sistergirls and Brotherboys who helped us write this statement.

July 2020

AusPATH and PATHA Welcome RACP Advice to Australian Minister Greg Hunt

The Australian Professional Association for Trans Health (AusPATH), established in 2009 as the Australian and New Zealand Professional Association for Transgender Health, is Australia’s peak body for professionals involved in the health, rights and wellbeing of trans people, including those who are gender diverse and non-binary (TGDNB). The AusPATH membership comprises approximately 300 experienced professionals working across Australia.

The Professional Association for Transgender Health Aotearoa (PATHA) is an interdisciplinary professional organisation working to promote the health, wellbeing and rights of transgender people in Aotearoa New Zealand. PATHA’s membership includes over 70 professionals who have experience working for transgender health in clinical, academic, community, legal and other settings.

AusPATH and PATHA welcome the Royal Australasian College of Physicians (RACP) advice to Minister Greg Hunt, Federal Minister for Health, regarding the care and treatment of TGDNB children and adolescents, including those seeking medical intervention. This advice is based on the available scientific evidence and the expertise of those with relevant clinical experience across sub-speciality areas of medicine and bioethics.

AusPATH and PATHA agree with the RACP that ensuring children and adolescents who are trans, including those who are gender diverse and non-binary “can access appropriate care and treatment regardless of where they live, should be a national priority”, and that “withholding or limiting access to care and treatment would be unethical and would have serious impacts on the health and wellbeing of young people.”

As stated by the RACP, clinical care needs to be “non-judgemental, supportive and welcoming for children, adolescents and their families”.

AusPATH and PATHA also support the RACP recommendation that the Australian Government provide funding for research, especially in relation to the long-term health and wellbeing outcomes for trans, including gender diverse and non-binary, young people. Increased investment in research and expansion of the knowledge base, for young people and adults, will be vital in improving the current and disturbing high rates of depression, anxiety, suicide attempts and suicide amongst this cohort.

Improving outcomes can only be achieved by reducing the stigma, discrimination, bullying and harassment that trans people, including those who are gender diverse and non-binary, are subjected to on a daily basis. Negative, hateful media campaigns aimed at invalidating the experiences and strength of this community, and those who provide care for them, is reprehensible, harmful and must stop.

There is much work for us to do to improve the lives of all trans people in Australia and Aotearoa New Zealand. Both AusPATH and PATHA look forward to assisting the clinicians, researchers, educators and advocates across our two countries to continue the provision of high quality, patient-centred, human rights-focused and comprehensive gender affirming care and treatment.

Further reading:

Royal Australasian College of Physicians’ Statement

Royal Australasian College of Physician’s Letter to Minister Hunt

Royal Children’s Hospital, Melbourne Statement

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents 

AusPATH Position Statement on the Hormonal Management of Adult Transgender and Gender Diverse Individuals

Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand

The AusPATH Board of Directors                            

6 March 2020

PATHA Executive Committee

11 March 2020

Also published by PATHA on 12 March 2020 HERE.

AUSPATH SUPPORTS INCLUSION OF GENDER IDENTITY IN THE 2021 AUSTRALIAN CENSUS

The Australian Professional Association for Trans Health (AusPATH) was established in 2009 (previously as the Australian and New Zealand Professional Association for Transgender Health) and is Australia’s peak body for professionals involved in the health, rights and well-being of trans, including gender diverse and non-binary (TGDNB), people. The AusPATH membership comprises approximately 250 experienced professionals working across Australia.

AusPATH supports the addition of meaningfully inclusive questions on gender identity within the 2021 Census.

Population estimates from cross-sectional studies, such as the National Survey of Australian Secondary Students and Sexual Health 2019, indicate that 2.3% of young people are trans, including  gender diverse or non-binary (TGDNB). However, despite the relatively large size of this population, no national population data exists.

It is well established that TGDNB Australians experience a range of health and wellbeing challenges at higher rates than the general population, but in order to establish the true extent of the issues and respond at an appropriate level, the number of TGDNB  people living in Australia must be known.

It is also well documented that the TGDNB population has a higher prevalence of mental health conditions such as depression, anxiety disorders, violence (including domestic violence), abuse, self-harm and suicide attempts compared to the general population. Knowing the population size and characteristics will allow the design and distribution of necessary health services to areas of need, and appropriate allocation of resources.

TGDNB people are included as a national priority in the 5th National Mental Health and Suicide Prevention Plan, and addressing the above issues is a necessity if this is to be a success. Additionally, while a paucity of data exists at a national level of the prevalence of TGDNB people living with HIV/AIDS, they are also considered a priority population in the 8th National HIV Strategy. Furthermore, for healthy ageing and aged care, TGDNB people are included in the 2012 National Lesbian, Bisexual, Transgender and Intersex (LGBTI) Ageing and Aged Care Strategy.

In light of the Federal Government’s commitment in these important policy areas, it becomes imperative that accurate and relevant data be collected at the national level to help address the diverse needs of TGDNB people. Without comprehensive, inclusive national data, essential planning of resources at a population level cannot be undertaken in these key areas. The 2021 Australian Census of Population and Housing offers the ideal opportunity to obtain accurate data to reflect the reality of the Australian population.

Collecting data on gender using options variables such as ‘male, female or trangender’ is contrary to best practice and is likely to confound analysis given that most TGDNB people are simply male or female. We recommend a two-step methodology, as per well-established and tested guidelines applicable to an Australian and global context.  This approach involves a question about the marker used to register an individual’s birth (male or female) alongside a second question about an individual’s gender identity (male, female or non-binary). These simple questions are easy to understand and would be acceptable to the broader general population.

This approach was not followed in the 2016 Census survey instrument resulting in an inadequate and inaccurate representation of Australia’s TGDNB population. The ABS confirmed this with a statement, ‘This count is not considered to be an accurate count, due to limitations around the special procedures and willingness or opportunity to report as sex and/or gender diverse’.

In summary, AusPATH believes that it is both important and possible to collect data on gender identity in a national census. This is of national importance, and such data will satisfy a vital need in enabling better health service delivery for the TGDNB population. The collection of such data will be acceptable to census respondents, and it can be collected accurately and efficiently. There is likely to be a continuing need for such data in future censuses.

Furthermore, AusPATH endorses previous statements made by the National LGBTI Health Alliance, Equality Australia, and Intersex Human Rights Australia (IHRA) in support of the meaningful inclusion of questions related to sexual orientation, gender identity and intersex status.

AusPATH supports the inclusion of a two-question format related to gender identity in the 2021 Australian Census.

AusPATH Board of Directors

18 December 2019

AUSPATH POSITION STATEMENT ON "RAPID-ONSET GENDER DYSPHORIA (ROGD)"

The Australian Professional Association for Trans Health (AusPATH) was established in 2009 and is Australia’s peak body for professionals involved in the health, rights and well-being of trans, including gender diverse and non-binary (TGDNB), people. The AusPATH membership comprises approximately 250 experienced professionals working across Australia.

The term “Rapid Onset Gender Dysphoria (ROGD)” is not a diagnosis or health condition recognised by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, “ROGD” is an acronym describing a proposed phenomenon, with insufficient peer-reviewed scientific evidence to support its implementation and/or use within clinical, community, social and legal settings1.

AusPATH affirms the rigorous processes by which diagnoses are developed and applied. These academic and clinical processes operate within professional medical organisations, and are developed by expert working groups of  scientists, clinicians, and stakeholders over long periods of time, with high levels of scientific scrutiny of the evidence-based literature. “ROGD” does not meet this standard, and therefore is not recognised by AusPATH.

Whilst many have a clear picture of their gender from a very early age, for others the journey towards understanding their gender is more prolonged. The timing of when an individual discloses their gender to others is a separate consideration and does not necessarily reflect the development of their experienced gender. Many do not disclose their identity, rather hiding it for fear of negative reactions from others, including family rejection, discrimination, stigmatisation and social exclusion. The term “Rapid Onset Gender Dysphoria” is not, and has never been, a diagnosis or health condition but has been used in a single report describing parental perception of their adolescent’s gender identity without exploration of the gender identity and experiences of the adolescents themselves.

AusPATH encourages continued scientific exploration within a culture of academic freedom, not censorship. All TGDNB people are deserving of gender-affirmative, evidence-based care that is underpinned by contemporary, adequately endorsed and community engaged standards of care and clinical guidelines.

AusPATH recognises the harms caused by conversion, reparative and aversion treatments and opposes any such efforts to invalidate an individual’s experienced gender. AusPATH supports affirmative responses to young people whereby self-reported gender is respected, and young people are able to safely explore their gender and expression without judgment, pathologisation or predetermined outcome. AusPATH urges caution in the use of any term that has the potential to invalidate a person’s gender.

AusPATH Board of Directors

30 September 2019

  1. WPATH (World Professional Association for Transgender Health) position on “Rapid-Onset Gender Dysphoria  (ROGD)” 4 September 2018

AUSPATH POSITION ON AFFIRMATIVE MODEL OF CARE

The Australian Professional Association for Trans Health (AusPATH) is an organization which actively promotes communication and collaboration amongst professionals involved in the health, rights and well-being of people who identify as trans, including gender diverse and non-binary (TGDNB). As such, we acknowledge and applaud contemporary research in this field which informs a better understanding of how best to assist TGDNB people of all ages.

An affirmative model of care for children and young people who identify as TGDNB is standard clinical practice in Australia and NZ. In 2017, AusPATH endorsed the Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents, a guideline based on empirical scientific evidence and expert clinical consensus. This was published in the Medical Journal of Australia and later endorsed through an editorial in The Lancet. As The Lancet editorial states, “Children and adolescents with gender dysphoria often experience stigma, bullying, and abuse, resulting in high rates of mental illness, including depression, anxiety, and self-harm. But with supportive, gender-affirming management, as laid out by the Australian guidelines, these consequences can be minimised.”

Gender-affirming care encourages clinicians to listen to the child or adolescent, and their families, and to support them to explore and express their identity as they wish to do so. For children who desire to socially transition, research demonstrates that following transition, these children can demonstrate levels of emotional functioning and self-worth which is comparable to their cisgender peers, and clinical observation supports the role of social transition in ameliorating distress within this population. Social and medical transition in adolescents is also associated with improved mental health outcomes as well as educational and vocational attainment equivalent to their cisgender peers.

There is extensive evidence that psychological practices undertaken in an attempt to change a person’s gender identity to be more aligned with the sex assigned at birth (known as conversion or reparative therapies) lack efficacy, are considered unethical and can cause harm to people’s health and well-being. Denying or withholding care is also potentially harmful and should not be considered a neutral stance. Any group or organisation that promotes practices that deny a person the opportunity to express their gender identity and access support and medical intervention to improve their health and well-being should not be endorsed nor their practices condoned.

ANZPATH Executive Committee
September 2018

AUSPATH STATEMENT ON LEGAL RECOGNITION OF GENDER IDENTITY

The Australian Professional Association for Trans Health (AusPATH) recognises the right of all people to legal identity recognition and to identity documents consistent with their gender and/or sex identity. Further, for optimal physical and mental health, all persons must enjoy the right to freely express their gender identity, whether or not that identity conforms to the expectations of others.

Legally-recognized documents matching self-identity are essential to the ability of all people to find employment, to navigate everyday transactions, to obtain health care, and to travel safely; Gender diversity should not preclude individuals from enjoying the legal recognition all citizens expect and deserve. Barriers to legal recognition may harm an individual’s physical and mental health.

AusPATH opposes surgery or sterilization requirements to change legal gender markers. No particular medical (including hormonal) or surgical procedure is an adequate indicator of a person’s gender identity. These should not be requirements for legal gender change. Living as one’s own identity for a year should suffice.

AusPATH recognizes that there is a spectrum of gender identities, and that choices of identity limited to “Male or Female” inadequately reflect them all. AusPATH supports the option of “X or Other” as a personal choice.

Marital status should not affect legal recognition of gender change, and appropriate legal gender recognition should be available to gender and/or sex diverse youth. The right to legal recognition of gender extends to those incarcerated or institutionalized. Court hearings create financial and logistical barriers to legal gender change, and may also violate personal privacy rights or needs.

Therefore, the Australian Professional Association for Trans Health urges governments to eliminate unnecessary barriers, and to institute simple and accessible administrative procedures for gender diverse people to obtain legal recognition of gender, consistent with each individual’s identity.

AUSPATH SUPPORT FOR THE WORLD PROFESSIONAL ASSOCIATION FOR TRANSGENDER HEALTH'S STATEMENT ON DE-PSYCHOPATHOLOGISATION OF GENDER VARIANCE

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative.

The psychopathologisation of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people.

©Australian Professional Association for Trans Health - Privacy Policy & Legals

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