AFFIRMATIVE MODEL OF CARE
The Australian and New Zealand Professional Association for Transgender Health (ANZPATH) is an organization which actively promotes communication and collaboration amongst professionals involved in the health, rights and well-being of people who identify as transgender, gender diverse or non-binary. As such, we acknowledge and applaud contemporary research in this field which informs a better understanding of how best to assist transgender and gender diverse people of all ages.
An affirmative model of care for children and young people who identify as trans or gender diverse is standard clinical practice in Australia and NZ. In 2017, ANZPATH 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
ANZPATH STATEMENT ON LEGAL RECOGNITION OF GENDER IDENTITY
The Australian and New Zealand Association for Transgender Health (ANZPATH) 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 and/or sex 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 and/or sex 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.
ANZPATH opposes surgery or sterilization requirements to change legal sex or 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.
ANZPATH recognizes that there is a spectrum of gender and/or sex identities, and that choices of identity limited to Male or Female inadequately reflects them all. ANZPATH 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 and New Zealand Professional Association for Transgender Health urges governments to eliminate unnecessary barriers, and to institute simple and accessible administrative procedures for gender and/or sex diverse people to obtain legal recognition of gender, consistent with each individual’s identity.
ANZPATH 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 psychopathologlisation 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.
Australasian Paediatric Endocrine Group DSD Working Group
APEG Council endorses the six guidelines referring to adolescent transsexuals that are contained in the paper, Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA et al: “Endocrine treatment of transsexual persons: an Endocrine Society Clinical Practice Guideline”. J Clin Endocrinol Metab 94: 3132-3154, 2009.
The six guidelines are as follows:
- “We recommend that adolescents who fulfil eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development”.
- “We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of oestradiol and testosterone, respectively), but no earlier than Tanner stages 2-3.”
- “We recommend that GnRH analogues be used to achieve suppression of pubertal hormones.”
- “We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 yr, using a gradually increasing dose schedule of cross-sex hormones.”
- “We recommend referring hormone-treated adolescents for surgery when 1) the real-life experience (RLE) has resulted in a satisfactory social role change; 2) the individual is satisfied about the hormonal effects; 3) the individual desires definitive surgical changes.”
- “We suggest deferring surgery until the individual is at least 18 years old.”
The DSD Working Group notes that in Australia, any hormonal treatment, including GnRH agonist treatment, being prescribed for a transsexual person under the age of 18 years, with the intention of it being part of a process preparing the individual for a desired sex change, is defined as a Special Medical Procedure requiring application to the Family Court of Australia.
The DSD Working Group also notes that the primary care managers and decision makers for transsexual adolescents are child and adolescent psychiatrists, and that the role of the paediatric endocrinologist is to provide safe and effective hormonal treatment following a recommendation given by the patient’s psychiatrists.
Garry Warne, Chair DSD Working Group November 4th 2010
The executive of ANZPATH has sought advice from the Australian Taxation Office (ATO) as to whether the 20% tax offset for medical expenses is applicable to legal expenses incurred in applications to the Family Court of Australia for Special Medical Procedures.
The ATO has given a “General Ruling” on this.
The advice is that the 20% tax offset would NOT apply to legal expenses.
A “Private Ruling” could be requested by individuals concerned , but would receive the same response.
Legal Aid may be available to minors for legal representation and to parents (means tested) though this may vary from state to state.
The Legal Services Commission in individual states should be consulted.
ANZPATH supports the Federal administration of "Marriage" and encourages the Federal Government to repeal the Marriage Act and replace it with a Civil Ceremony (Union), (Contract) Act available to mm, mf,and ff couples. Churches would be free to offer 'sacramental ' Marriage to whom they wished. This would achieve separation of 'Church' and 'State' as with a number of European nations.
ANZPATH supports the repeal of the South Australian Sexual Reassignment Act (1988). It is the only Act of its type in all jurisdictions in the world. For the same reason Anzpath supports the withdrawal of The Family Court of Australia from its involvement in the medical management of adolescents with Gender Incongruence.
ANZPATH supports the unification of 'legal gender change laws' in Australia.
COAG should be encouraged to urgently address this issue.
ANZPATH is alarmed at the failure to provide, and the withdrawal of medical services to those with Gender Incongruence, by the Australian Public Hospital System. This absence of, and at times refusal of service is possibly in breach of various Anti-Discrimination Acts.
Letter to the Federal Minister for Health
17 March 2015
The Honourable Sussan Ley MP
Minister for Health
I am writing to you in my capacity as President of ANZPATH - the Australian and New Zealand Professional Association for Transgender Health. This organisation wishes to express its deep concern in relation to ongoing discussions, published in Australian Doctor, relating to proposed changes to the prescribing of testosterone by general medical practitioners under the PBS. Many members of this organisation are medical practitioners (general practitioners, sexual health physicians, psychiatrists, endocrinologists, surgeons, paediatricians) who specialise in transgender health. Treatment with testosterone is an essential therapy for the majority of our trans-male identified patients. This is a group of patients who are disenfranchised, marginalised and have high rates of psychiatric morbidity and mortality. Current research demonstrates that this group of patients is most at risk of depression and suicide between the time they decide to proceed with gender affirmation treatments and the time they are able to access those treatments.
The proposed restrictions on general practitioner prescribing of testosterone will place this vulnerable group of patients at even greater risk of psychiatric morbidity and mortality given the inevitable delays in accessing treatment that the proposed prescribing changes to the PBS will entail. The lack of wider consultation in relation to the proposed changes is deeply concerning to this organisation. The negative implications for the transgender population which has clearly not received adequate consideration is also of great concern. It is our understanding that the proposed changes are due for implementation from April 1, 2015. We are of the opinion that urgent reconsideration of these changes is needed and that ongoing prescription of testosterone by general practitioners experienced in transgender health should continue without the added restriction of referral to a limited number of medical specialists. We would appreciate a prompt response to this submission.
Dr Fintan Harte,
Letter to Mr Peter McEvoy, Executive Producer Q&A, Australian Broadcasting Corporation
ANZPATH (Australian and New Zealand Professional Association for Transgender Health) wishes to express deep concern in relation to misleading “facts” presented by Mr Lyle Shelton, managing director of the Australian Christian Lobby on the ABC’s Q&A program on Monday, 29 February 2016. On the program, Mr Shelton stated that the suicide rate in people who had undergone sex reassignment surgery was 20 times higher than the general population 10 years after having had the surgery. The implication was that sex reassignment surgery was not an effective treatment for gender dysphoria. The facts quoted were from a study titled “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden” which was published by Cecilia Dhejne et al. in PLoS ONE, February 2011/ Volume 6 / Issue 2. What Mr Shelton failed to state was the authors in their paper quoted several other studies “that suggest that sex reassignment of transsexual persons improves quality of life and gender dysphoria”. The authors went on to state “it is therefore important to note that the current study is only informative with respect to transsexual persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.” A study by G. De Cuypere et al. Titled “Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery” published in Sexologies 15 (2006) 126-133, the authors stated “although the suicide attempt rate dropped significantly from 29.3% to 5.1%, it was definitely higher than in the average population”. The mental health problems associated with being transgender, including the higher risk of suicide, is not inherently due to being transgender itself but due to the stigma, discrimination, exclusion and disadvantage inflicted by society. Society’s views of transgender individuals is unchanged by an individual’s decision to undergo sex reassignment surgery, hence the high suicide rate in the Swedish study even post operatively. However, society’s negative views of transsexualism can be reinforced when misinformation and trans-phobic commons are broadcast on national television.
In support of his argument that sex reassignment surgery was not an effective treatment for transsexualism, Mr Shelton went on to cite the closure of the Johns Hopkins Gender Identity Clinic in 1979 by Dr Paul McHugh as support for his argument. Mr Shelton describes McHugh and his colleagues as “pioneers” in the field. Sex reassignment surgery was being carried out in Melbourne, at the Royal Melbourne Hospital, in the 1960s. McHugh’s decision to close the Johns Hopkins clinic was based on research carried out in 1979 by Dr Jon Meyer, one of McHugh’s staff psychiatrists. The research is outdated and methodologically flawed. Despite the research showing that patients who had undergone sex reassignment surgery reported subjective satisfaction post operatively and a low regret rate, McHugh (a Conservative Catholic) decided to close the clinic on the basis that patients did not show “sufficient” improvement on socio-economic and other parameters. McHugh’s views have been widely criticised as outdated. He ignores extensive research over the past 30 years which clearly shows the efficacy of medical and surgical interventions for gender dysphoria in children, adolescents and adults. McHugh’s view that transsexualism is inherently psychopathological is no longer held by mental health professionals working in the field. Many take the view that transgenderism is simply a reflection of nature’s diversity. Diversity is how we have evolved as a species but while nature loves diversity, society does not. McHugh’s support for “reparative” psychological treatment has been outrightly rejected by WPATH (World Professional Association for Transgender Health) and ANZPATH. In some countries such as Canada, this therapy has been made illegal.
Mr Shelton went on to criticise Minus18, a support group for LGBT youth, and described the “sexualised content” of their publications as “horrific”. We feel his language is emotive and he fails to understand the intense gender dysphoria that drives young birth assigned females (who identify as male) to bind their breasts and young birth assigned males (who identify as female) to tuck their penises. Minus18 does not encourage these behaviours but gives accurate advice regarding safety to young people who feel compelled to follow these procedures to alleviate their intense gender dysphoria.
Mr Shelton goes on to argue that treatment for transgender children remains “contested”. Within the medical and scientific community this statement is untrue. Without treatment during childhood and adolescence, 50% of adolescents self-harm and 28% attempt suicide (Hillier 2010). In contrast, young people with access to puberty blockers and hormones during adolescence had significantly reduced depression and anxiety with their quality of life, educational and vocational outcomes being equivalent to that of the general population (De Vries 2014).
He cites research claiming that 80% of transgender children, if left untreated, reconcile with their birth assigned gender. This statement is also not a true reflection of the research as these studies looked at children showing “gender non-conforming behaviour” but whom did not necessarily meet the full criteria for gender dysphoria. These children were not necessarily living in supportive environments and sufficient follow-up studies have not been conducted. This figure, therefore, is likely to significantly under-estimate the number of young children who persist with their transgender identification into adolescence. Once a young person reaches puberty (usually at the age of between 9-12 years) studies show the persistence rate is as high as 99.5%. The experience at the Royal Children’s Hospital in Melbourne is that the majority of young children who satisfy the diagnostic criteria for gender dysphoria in childhood and who have the benefit of supportive home and school environments, persist with gender dysphoria into adolescence and adulthood.
ANZPATH sincerely hopes that any further ABC television debates on this subject will be informed by accurate current scientific data presented by professionals who are expert in the field. It is regrettable that no gender health specialist or trans-identified person was represented on the Q&A panel discussion on Monday, 29 February 2016.