We need freedom to debate treatment for patients with gender dysphoria

We need freedom to debate treatment for patients with gender dysphoria

The Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) position statement on gender dysphoria acknowledges there are different perspectives on the treatment of trans patients. Last week, we heard from professionals representing those different perspectives.

One clinical psychologist, Dr Sandra Pertot, penned an article in the Sydney Morning Herald (SMH) saying the position statement had given her hope that at last it might be possible for Australian professionals to engage in “an evidence-based and client-centred conversation about the best way to treat and support young people experiencing symptoms of gender dysphoria or gender incongruence”. Two days later, another SMH article, this time authored by Associate Professor Sam Winter, sought to quash this hope by declaring that the science was in, “the experts” had formed a consensus and further discussion is neither needed nor welcome. 

Winter is Chair of the policy committee for the Australian Professional Association for Trans Health (AusPATH) – “the key organisation” in “the gender-affirming space”. He explains that “unlike … the RANZCP, [the membership of AusPATH] consists entirely of professionals working with trans people”. AusPATH members are unanimous in advocating the “gender affirmation/informed consent” approach, which Winter describes as “a non-judgmental, respectful, shared-decision making approach to supporting a person in their gender, in a way that is tailored to their individual needs”. According to Winter, “the vast majority of trans people, including youth, benefit from the gender-affirming model. It ain’t an experimental approach”.

By contrast, Winter characterises clinicians like Pertot, who argue that psychotherapy is essential to helping trans patients, as a “fringe clique”, “teasing away and probing and questioning patients to help them understand why they feel as they do; locating a basis for their trans identity, all in the hope that if a trans person can only understand themselves and their deep hidden past more clearly, then they will no longer be trans”.

Winter even suggests psychotherapists who inquire too deeply might be a danger to their patients:

“Worryingly, there is only a small step between psychotherapy of this sort and reparative therapy (often dubbed conversion therapy), an often downright coercive approach aimed at “curing” the person of their identity – making them “desist”. That approach is illegal in some jurisdictions and is condemned by professional associations worldwide for its ineffectiveness and capacity for harm. Worst of all, I have seen this psychotherapeutic approach recommended as a replacement for more orthodox care.”

Winter’s description of medical gender affirmation as “orthodox” and his dismissal of conventional psychotherapy as “experimental” leaves no doubt about where his loyalties lie.

By collapsing all distinctions between conventional psychotherapy and coercive “aversion” therapies – historically used in the context of same-sex attraction – Winter is grossly misrepresenting the approach and motivations of regular clinicians. Dr Pertot, for example, states that she is not against medical transitioning. Over the course of 45 years in clinical practice, she is proud to have assisted many patients to transition and reports that “the majority who did transition were happy with their new lives”.

Pertot is, however, concerned about the new pattern that others, like Abigail Shrier and Lisa Littman, have also observed; namely, increasing numbers of young women – often socially isolated and/or with mental comorbidities but with no prior indications of discomfort with their female bodies – who have self-diagnosed as trans or gender diverse having learned about these things online. Pertot locates the beginning of the trend from 2014, but it was some years before that she became aware of other clinicians who were noticing the same phenomenon. 

Like Abigail Shrier and Lisa Littman, Dr Pertot has now been censured for publicly expressing her concern about the unquestioning medical “affirmation” of masculine gender identities for these young women. 

“Earlier this year I was the subject of a formal complaint – my first in 45 years of working as a clinical psychologist. The complaint was brought by a group of people from the transgender community who objected to views I expressed in a podcast for the Australian Psychological Society.” 

One of the central points in contention between those who favour the “affirmation/informed consent” approach and those who favour the “psychotherapeutic” approach to gender dysphoria concerns whether, and how much, a clinician or doctor should question the aetiology of a patient’s gender identity before prescribing puberty blockers and cross-sex hormones. 

Winter is indignant at RANZCP’s suggestion that therapists following the affirmation/informed consent approach “will never question what a young trans person tells them”. “Really?”, he writes. He strongly implies this is not true: “One wonders if the college had any specialist trans healthcare providers on the panel that produced this statement.” Further, Winter concedes that the existence of “de-transitioners” implies “a need for careful assessment ahead of gender-affirming medical care”. But, and Winter is absolutely adamant about this: “the key point is this: in Australia a young person can be confident of getting that sort of careful assessment.”

While this reassurance will be welcome news to many critics of the affirmation/informed consent model, it is not necessarily congruent with Winter’s previously stated condemnation of psychological assessment. Nor is it supported by client-facing communications offered by trans health services. For example, anyone approaching TransHub (a website established by the AIDS Council of New South Wales (ACON)) is presented with an explanation of the transition process that is manifestly free of any psychological assessment.

TransHub readers are told that the process might involve 2-3 visits with a GP, during which they can expect to be asked about all manner of things pertaining to their physical health, medical and family history, previous hormonal or gender affirmation experience, specific risk factors such as a history with migraines, liver disease, seizures, breast tissue lumps and irregular bleeding; current medications, allergies, if you smoke, how much you drink or use drugs, and how much support you have at home, and at work; fertility goals and reproductive health needs (including information about fertility preservation); last cervical screen, STI test, what contraception methods you use, if you’ve had a bowel cancer screen, etc. Blood tests are needed to establish baseline levels of estrogen, testosterone and a range of other indicators such as liver function, thyroid levels, cholesterol, full blood count, electrolytes, glucose, lipids, and if applicable, pregnancy. Blood pressure and weight are checked. 

The website further explains that “Throughout this process, your doctor will be assessing that you understand what’s going on, have the capacity to make an informed decision and consent to treatment, ensuring that you are making a decision of your own free will.” After that, it’s time to sign some informed consent paperwork to ensure the patient has understood “what the risks, impacts and outcomes might look like”, and that they “consent to the process”.

The sort of careful psychological assessment that might work to reduce the risk of transition regret or detransition – the “sort of careful assessment” that Winter says we can all be “confident” is happening as a matter of course in Australian practice, appears to be missing from TransHub’s outline of the “affirmation/informed consent” procedure. Instead, TransHub tells readers:

“In NSW, people aged 18+, who are able to consent to their own medical care, can initiate (or start) gender affirming hormones with a GP under the informed consent/affirmation enablement model…[I]f you do feel like medical affirmation is the right path for you, you deserve to be supported in that decision, no matter how you identify. At the end of the day, it’s your body, and the choices you make about how you affirm your gender are yours to make.”

Until July this year, TransHub was advertising this psychology-free pathway to transitioning for anyone who wanted it over the age of 16. When Professors Philip Morrison and Patrick Parkinson pointed out that this was incorrect – that doctors following TransHub’s recommendations would be exposed to significant legal liability – TransHub responded quickly to correct the error. Their advice now correctly notes that “affirmation/informed consent” treatment without a formal psychological diagnosis of gender dysphoria is only available to patients over the age of 18.

On a microcosmic scale, this vignette illustrates how open, multi-disciplinary professional discussion is vital for the avoidance of error. Since patients are the first to suffer from professional mistakes, therapists on all sides of this debate who claim to prioritise patient welfare should therefore allow space for divergent professional opinion. By the same token, the efforts of Winter to foreclose on that debate, to claim expert consensus is on the side of psychology-free affirmation and to impugn the professional ethics of those who take a different view, must work against the interests of the very patients he claims to champion.

Winter’s characterisation of psychotherapy as “dangerous” and “experimental” and of medical interventions as “orthodox” and “established” is obviously highly contestable but, even were it true, the freedom to challenge established conclusions is fundamental to scientific progress and the detection of error. The assertion of dominance is no reason to deny the right of others to challenge the claims of an incumbent. Rather, the impulse to suppress or limit open scientific debate should always raise concern that something other than patient welfare is being protected.

For these reasons WFA joins Dr Pertot in hoping that the RANZCP’s position statement encourages other professionals to engage in the robust, good-faith dialogue that can only improve our understanding of gender dysphoria in general and why this has now started affecting post-pubertal adolescents and young women in unprecedented numbers. Surely such dialogue, the rigorous scrutiny of different claims, the challenging of settled assumptions, can only improve our ability to help these patients.