AusPATH: Public Statement on Gender Affirming Healthcare, including for Trans Youth

26 June 2021

Trans people, including women, men, non-binary people and those who are gender diverse (henceforth trans people), experience their gender as incongruent to that presumed for and assigned to them at birth (e.g. Coleman et al, 2012; WMA, 2017). This contrasts with cisgender (cis) people, whose gender is congruent to that presumed for and assigned to them at birth.

Being trans is not a new experience of gender, indeed the trans experience can be traced throughout human history and is widely regarded as an aspect of human diversity, rather than as a mental disorder (e.g. APA, 2014; WMA, 2017; WHO, 2019).

Many trans people become aware of a gender incongruence in childhood or adolescence (e.g. Coleman et al, 2012; Heylens et al, 2014; Zaliznyak 2020). A recent Australian survey found that 2.3% of high-school aged young people sampled were trans (Fisher et al., 2019).

The basis for development of gender is not well known. There is evidence pointing to a range of factors including biological predisposition of a cis or trans experience of gender and/or gender identity (e.g. Korpaisarn and Safer, 2019; Perrotta,2020; Ristori et al, 2020; Foreman 2019; Roselli 2018; Polderman 2018). The evidence for environmental origins for the trans experience is sparse and flawed (see e.g. Winter et al, 2016 and Turban 2020 for more on this).

Gender incongruence is a term used to describe a condition related to sexual health, which may have implications for healthcare such as requiring access to medical gender affirmation (e.g. WHO, 2019, US Endocrine Society 2020).

Trans people may experience gender-related discomfort or distress, called gender dysphoria, which may stem from the experience of others not recognising one’s identity and/or awareness that one does not have a socially recognised body that represents one’s known identity (e.g. APA, 2013; Winter et al, 2016).

Affirmative support for trans people, especially from their parents, friends and additionally for young people their school environments, is vital for maintaining good mental health (e.g. Travers et al, 2012; Simons et al, 2013; Hill et al, 2020; Ullman, 2021). Social support from family, friends and school environments is associated with reduced suicide risk (e.g. Edwards et al. 2019; Bauer et al., 2015; Hill et al, 2020). Family and school rejection are associated with increased risk of suicidal ideation (e.g. Chen et al. 2019 ) and suicide attempts (e.g. Klein & Golub, 2016; Hill et al, 2020). It is vital that parents and families are able to access supportive mental health and peer support, as needed while they adjust, in order to preserve and strengthen positive family relationships.

A supportive environment allows for gender affirmation; social and, where sought, medical and legal affirmation.

Social affirmation (names, pronouns, hairstyles, clothes etc) has been shown to provide benefits to many trans people, especially trans youth (e.g. Olsen et al, 2016; Durwood et al, 2017; Russell et al, 2018). Medical affirmation can involve a broad range of healthcare support, delivered by way of a gender affirming approach to healthcare. Legal affirmation involves the updating of legal identity across institutions and with the state.

Gender affirming healthcare is the widely accepted standard in the field (see the list of professional and scientific organisations endorsing this approach at the end of this document). It is a non-judgemental, respectful, shared-decision making model to support a person in their gender in a way that is tailored to their individual needs. Shared-decision making draws on and respects the ability and agency of most clients, including many trans youth, to provide informed consent for their healthcare. Gender affirming healthcare emphasises affirming language, psychological and peer support, support for social affirmation, and/or medical affirmation (e.g. puberty blockers for young adolescents, or feminising or masculinising hormones and/or surgery for older clients), as medically necessary and clinically relevant.

The degree of psychological support may vary depending upon an individual’s medical, psychological or social circumstances and needs. Particularly in adolescence, a gender affirming approach does not negate the need for comprehensive exploration of early developmental history, history of gender development and expression, history or trauma or abuse, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as family support (Riley, 2015). For more information on the gender affirming approach see Keo-Meier and Ehrensaft (2018), and numerous documents produced by professional and scientific organisation listed at the end of this document.

Medical and surgical affirmation can frequently alleviate gender-related distress and yield a variety of other benefits to the individual (e.g. de Vries et al, 2011ab; Edwards-Leeper et al, 2012; Khatchadourian et al, 2014; WHO, 2015; Wylie et al, 2016, White Hughto and Reisner 2016, de Vries et al, 2014, Costa et al, 2015, Mahfouda et al, 2017, Olson-Kennedy et al, 2018; Mahfouda et al, 2019; Allen et al, 2019; Turban 2020, Achille et al, 2020; van der Miesen et al, 2020). Medical affirmation when needed (including hormonal and surgical intervention) is associated with reduced risk of suicidal ideation (e.g. Bauer et al. 2015; Tucker et al. 2018).

Different trans people affirm their gender in different ways. It is not inevitable that a trans person seeks medical gender affirmation, indeed many do not (e.g. Nieder et al, 2020; Quinn, 2020). This is especially true for surgery, which is in any case usually only available to adults (e.g. Coleman et al, 2012; Hembree et al, 2017).

Widely used guidelines for provision of gender affirming healthcare respect the agency and autonomy of trans people, while also stressing the importance of engagement and assessment between patient and treating physician (e.g. Coleman et al, 2012; Deutsch, 2016; Steensma et al, 2017, Hembree et al, 2017).  As a consequence of adherence to these carefully developed guidelines, gender affirming healthcare is associated with very low rates of regret and de-transition, including as they apply to trans youth (e.g. de Vries et al, 2014; Wiepjes et al, 2018; Brik et al, 2020). Where de-transition occurs, it is often a consequence of external pressures (e.g. Turban et al, 2021).

Despite widespread professional and scientific consensus on gender affirming healthcare (see list of organisations later in this document), in Australia accessible multi-disciplinary services for trans youth are sparse, and there remains a dearth of gender affirming GPs in the primary care system. People seeking culturally-safe gender affirming medical care often encounter barriers of availability, cost and competence (as documented in e.g. Rosenberg, S, Carman, M, Bourne, A, Starlady, Cook, T, 2021). They, their families and healthcare providers also encounter legal barriers (e.g. the recent Re: Imogen decision in the Family Court of Australia, as critiqued in Jowett and Kelly, 2021), media hostility (as documented in e.g. Garcia and Badge, 2021).    

Psychotherapy can have a role to play within a broadly gender affirmative approach (e.g. Coleman et al, 2012). However, the evidence on the benefits of such an approach used outside (and/or instead of) more orthodox gender affirming healthcare is strikingly sparse and anecdotal; a flaw evident in e.g. D’Angelo (2020) and D’Angelo et al (2021). Indeed, the judge in the Re:Imogen case accepted evidence that such an approach is ‘risky and unproven’ (para.226; Family Court of Australia, 2020). For its part, AusPATH notes the absence of any group studies justifying any confidence in the approach, and would be anxious for the welfare of any participants were any such study to be conducted.

In the absence of more information on these psychotherapeutic approaches, AusPATH is concerned that these approaches may involve pressure on the person to conform to the gender presumed for them at birth –  and that they therefore verge on “reparative therapy” (also called “conversion therapy”) similar to that used to ‘treat’ non-heterosexual sexualities.

AusPATH encourages and supports comprehensive, trans-affirming and inclusive mental health support if desired by individuals, and to support individuals in exploring their gender, but rejects gender identity change efforts (reparative or conversion therapy). Recalled exposure to attempts at conversion therapy are associated with significantly higher odds of lifetime suicide attempts and severe psychological distress (e.g. Turban et al  2019; Stonewall, 2020). Evidence from Australia underlines the risks of these approaches (e.g. Jones et al, 2020). Many professional and scientific organisations have spoken out against these approaches as used with people of diverse sexualities and/or genders. For updated listings see APS, HRC (undated) and two important consensus documents for the USA (Various organisations, undated) and the UK (Various organisations, 2017).  The UN independent expert on protection against violence and discrimination based on sexual orientation and gender identity has called for a global ban on conversion therapy (Madrigal-Borloz, 2020). A range of jurisdictions overseas and in Australia have banned these practices (see e.g. ILGA World, 2020; Starcevic, 2020).

In view of substantial evidence for the benefits of gender affirming healthcare which includes psychological support as needed, the relative lack of evidence for any benefits from psychotherapy used outside and/or instead of gender affirming healthcare, and the risk of harm where such approaches constitute reparative therapy, AusPATH believes that psychotherapeutic (including psychoanalytic) approaches used outside and/or instead of gender affirming healthcare are experimental, risk harm, raise ethical concerns.

AusPATH cautions that a recent critique of healthcare approaches for trans children and adolescents (Kozlowksa et al, 2021) should not be used to undermine current widely accepted practice.

To be unequivocally clear, AusPATH reaffirms its commitment to gender affirming healthcare, and asserts that any approach that would offer psychotherapy as an alternative to gender affirmative healthcare (i.e. offered while gender affirming healthcare is withheld or withdrawn) involves the risk of harm to the health and welfare of the clients concerned, whether they are trans youth or adults. 

A large number of professional and scientific organisations worldwide support and advocate gender affirming approaches to healthcare for trans people, including trans youth. In addition to AusPATH, the following professional and scientific associations have all published endorsements (be they position statements or guidelines etc) in support of the approach. The list below, confined to English-language documents, is not intended to be exhaustive.

AusPATH Board, June 2021
Special thanks to the AusPATH Policy Committee

Some documents supporting gender affirming approaches that refer to work with trans people of all ages.

World Medical Association (WMA). (around 115 member (mostly national) physicians’ associations).  See World Medical Association statement on transgender people (2018), at https://www.wma.net/policies-post/wma-statement-on-transgender-people/

World Professional Association for Transgender Health (WPATH). (around 2400 members). See Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (2012), at https://www.wpath.org/publications/soc  

Endocrine Society. (around 18000 members). See  Clinical Practice Guidelines for Treatment of Gender-Dysphoric/Gender-Incongruent Persons (2017), at  https://doi.org/10.1210/jc.2017-01658

Professional Association for Transgender Health Aotearoa (PATHA). (around 100 members). See Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People and Adults in Aotearoa, New Zealand (2018), at: https://patha.nz/Guidelines

American Psychological Association (APA). (around 121000 members). See Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (2015), at: https://www.apa.org/practice/guidelines/transgender.pdf

Australian Psychological Society (APS). (around 24000 members) See Australian Psychological Society recommends mental health practices that affirm transgender people’s experiences (undated) at: https://www.psychology.org.au/getmedia/00cd6bab-650a-431b-bc67-fdfb69729b83/Info-Sheet-Transgender-affirmation-extended-version.pdf

Australian Psychological Society (APS). Use of psychological practices that attempt to change or suppress sexual orientation or gender: Position statement (undated) at: https://www.psychology.org.au/About-Us/What-we-do/advocacy/Position-Statements/psychological-practices-conversion-practices

Royal College of Psychiatrists (RCPsych). (around 15000 members) See Supporting transgender and gender-diverse people (2018), at: https://www.rcpsych.ac.uk/pdf/PS02_18.pdf

TransHub. 2020. This section of TransHub is for health professionals who are seeking to strengthen the clinical care they deliver to trans patients and clients. It was written in collaboration with leading health professionals who specialise in the healthcare and affirmation needs of trans people across Australia and has been endorsed by AusPATH, at: https://www.transhub.org.au/clinicians

Some documents supporting gender affirming approaches that specifically concern work with youth  

American Academy of Child and Adolescent Psychiatry (AACAP). (around 9500 members). See Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth (2019), at: https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx

American Academic of Pediatrics AAP). (around 67000 members) See Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents (2018), at https://pediatrics.aappublications.org/content/142/4/e20182162

Australian Psychological Society (APS). (around 24000 members) See Transgender and gender diverse children (undated), at https://www.psychology.org.au/getmedia/03213f59-9b8f-45b9-8575-2605958fd791/Trans-and-gender-diverse-children.pdf

World Professional Association for Transgender Health (WPAT, around 2400 members), United States Professional Association for Transgender Health (USPATH, around 1700 members), and European Professional Association for Transgender Health (EPATH, around 200 members). See WPATH/USPATH/EPATH statement in response to calls for banning evidence-based supportive health interventions for transgender and gender diverse yout (2019), at https://www.wpath.org/media/cms/Documents/Public%20Policies/2019/FINAL%20Statement%20in%20Response%20to%20Calls%20for%20Banning%20Evidence-Based%20Supportive%20Health%20Interventions%20for%20Transgender%20and%20Gender-Diverse%20Youth%2011-20-2019.pdf

World Professional Association for Transgender Health (WPATH), European Professional Association for Transgender Health (EPATH), United States Professional Association for Transgender Health (USPATH), Asian Professional Association for Transgender Health (AsiaPATH), Canadian Professional Association for Transgender Health (CPATH),  Australian Professional Association for Trans Health (AusPATH), Professional Association for Transgender Health Aotearoa (PATHA). See WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, PATHA Response to Bell v. Tavistock Judgment Statement Regarding Medical Affirming Treatment including Puberty Blockers for Transgender Adolescents (2020), at  https://www.wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Statement%20Regarding%20Informed%20Consent%20Court%20Case_Dec%2016%202020.docx.pdf?_t=1608225376

Royal Australasian College of Physicians (RACP). (around 17000 members). See RACP statement on gender dysphoria (2020), at https://www.racp.edu.au/news-and-events/media-releases/racp-statement-on-gender-dysphoria

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