Psychiatrists Shift Stance on Gender Dysphoria, Recommend Therapy

Becky McCall

October 07, 2021

A new position statement from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) stresses the importance of a mental health evaluation for people with gender dysphoria — in particular for children and adolescents — before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries, often referred to as "gender-affirming care."

"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," the guidance states.

Because gender dysphoria "is associated with significant distress...each case should be assessed by a mental health professional, which will frequently be a psychiatrist, with the person at the center of care. It is important the psychological state and context in which gender dysphoria has arisen is explored to assess the most appropriate treatment," it adds.

The move by the psychiatry body represents a big shift in the landscape regarding recommendations for the treatment of gender dysphoria in Australia and New Zealand.

Asked to explain the new RANZCP position, Philip Morris, MBBS, FRANZCP, said: "The College acknowledged the complexity of the issues and the legitimacy of different approaches."

Exploration of a patient's reasons for identifying as transgender is essential, he told Medscape Medical News, especially when it comes to young people.

"There may be other reasons for doing it and we need to look for those, identify them and treat them. This needs to be done before initiating hormones and changing the whole physical nature of the child," he said.

"A cautious psychotherapy-first approach makes sense. If we can do that with adolescents then we will take a big step in the right direction," stressed Morris, who is president of the National Association of Practising Psychiatrists in Australia.

Keira Bell Case and Scandinavian Stance Lead to More Open Discussion

The rapid rise in gender dysphoria among adolescents in the Western world, referred to as "rapid-onset" or "late-onset" gender dysphoria, has seen a huge increase in the number of natal girls presenting and created frenzied debate that has intensified worldwide in the last 12 months about how tobest treat youth with gender dysphoria.

Concerns have arisen that some transgender identification is due to social contagion, and there is a growing number of "detransitioners" — people who identified as transgender, transitioned to the opposite gender, but then regretted their decision, changed their minds, and "detransitioned" back to their birth sex. If they have had hormone therapy, and in some cases surgery, they are left with irreversible changes to their bodies.

As a result, Scandinavian countries, most notably Finland, once eager advocates of the gender-affirmative approach, have pulled back and issued new treatment guidelines in 2020 stating that psychotherapy, rather than gender reassignment, should be the first line of treatment for gender-dysphoric youth.

This, along with a landmark High Court decision in the UK regarding the use of puberty-blocking drugs for children with gender dysphoria, brought by detransitioner Keira Bell, which was recently overturned by the Appeal Court, but which Bell now says she will take to the Supreme Court, has led to a considerable shift in the conversation around treating transgender adolescents with hormonal therapy, says Morris.

"This [has moved from]...a topic that could previously not be talked about freely to one that we can discuss more openly now. This is a big improvement. Previously, everyone thought it was all settled but it's not, certainly not from a medical angle," he states.

At Odds With Prior Australian Recommendations

The RANZCP had previously endorsed the standard guidelines of the Royal Children's Hospital (RCH) Melbourne, followed by most gender-identity services in Australia, and similar guidance from New Zealand, which both recommend gender-affirming care.

"Increasing evidence demonstrates that with supportive, gender-affirming care during childhood and adolescence, harms can be ameliorated and mental health and well-being outcomes can be significantly improved," state the RCH guidelines.

But in 2019, RANZCP removed its endorsement of the RCH guidelines and started a consultation, which resulted in the new position statement.

However, Ken Pang, MD, of the Murdoch Children's Research Institute in Melbourne and an author of the RCH guidelines, says the key recommendations of the new RANZCP position statement are consistent with their own guidelines.

The former note "the need for a skilled mental health clinician in providing comprehensive exploration of a child or adolescent's biopsychosocial context," Pang says.

However, it's difficult not to see the contrast in stance when the new RANZCP statement maintains: "Research on gender dysphoria is still emerging. There are polarized views and mixed evidence regarding treatment options for people presenting with gender identity concerns, especially children and young people."

Pang says the RCH guidelines do, however, recognize the need for further research in the field.

"I look forward to being able to incorporate such research, including from our own Trans20 study, into future revisions of our guidelines," he told Medscape Medical News.

Watch Your Backs With Affirmative Therapy: Will There Be a Compromise?

Morris says there will obviously be cases where "the child might transition with a medical intervention, but that wouldn't be the first step."

And yet, he adds, "There are those who push the pro-trans view that everyone should be allowed to transition, and the doctors are only technicians that provide hormones with no questions asked." 

But from a doctor's perspective, clinicians will still be held responsible in medical and legal terms for the treatments given, he stressed.

"I don't think they will ever not be accountable for that. They will always need to determine in their own mind whether their actions have positive value that outweigh any disadvantages," Morris continues.

The RANZCP statement does, in fact, stress just this.

All healthcare professionals need to "be aware of ethical and medicolegal dilemmas" pertaining to affirmative therapy, it indicates. "Psychiatrists should practice within the relevant laws and accepted professional standards in relation to assessing capacity and obtaining consent..."

Morris hopes there will ultimately be many more checks and balances in place, and that courts and clinicians will need to step back and not assume every child who seeks to transition is doing it as a result of pure gender dysphoria.

He predicts that things will end in a compromise. 

"In my view, this compromise will treat children with respect and approach them like any other patient that presents with a condition that requires proper assessment and treatment."

"In the end, some cases will be transitioned but there will be fewer than [are] transitioned at the moment," he predicts.

Morris has reported no relevant financial relationships. Pang is a member of the Australian Professional Association for Trans Health and its research committee.

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