
Psychiatrists have been alerted to the ethical and legal risks of medicalised gender change for young people and the lack of good evidence on whether it helps or harms.
The Royal Australian and New Zealand College of Psychiatrists has adopted a new, more cautious policy towards the “gender affirming” treatment approach spearheaded in Australia by the Royal Children’s Hospital Melbourne.
“The college has moved from a position of unquestioning acceptance of the affirmation model, as presented by the treatment guidelines of RCH, to an awareness of the complexity of the issues and the legitimacy of different approaches,” said Gold Coast clinician Philip Morris, president of the National Association of Practising Psychiatrists, which adopted a cautious psychotherapy-first approach last year.
The college’s new policy on gender dysphoria — a condition of bodily distress diagnosed in fast-growing groups of teenagers, chiefly girls, who identify as transgender — highlights the “paucity” of quality evidence on the outcomes of “affirmative” hormonal drugs and surgery such as mastectomy.
The college hints at the risk of lawsuits, warning its members of the “ethical and medico legal dilemmas” posed by these life-altering medical interventions given within a legal framework that is “rapidly changing”.
It says “evidence and professional opinion is divided” on whether the affirmative approach should be used with children, reminds psychiatrists of the changes in identity and brain development that come with childhood and adolescence, and insists that judgments about the capacity of minors to consent to treatment should be clearly documented.
Gender clinics claim the stark choice that faces parents of a distressed child is the affirmative model of social and medical transition or “doing nothing”.
But the college recognises psychotherapy as a non-medical option for patients with gender dysphoria and mental health issues, and emphasises the need for comprehensive assessment, which militates against uncritical “affirmation” of a young person’s self-diagnosis.
The new policy was welcomed by Roberto D’Angelo, president of the Society for Evidence-Based Gender Medicine, which is critical of gender clinics for operating with low-quality research data.
“I think it represents a significant improvement over the previous (policy), mostly because it really highlights the substantial deficits and uncertainties in the research and evidence base for gender dysphoria treatment,” Dr D’Angelo said.
He noted the college’s attention to the context in which gender dysphoria arises.
“That is a very pleasing move back to what psychiatry is all about, which is looking at the whole person in context,” he said.
“Gender dysphoria isn’t an isolated kind of biological problem; it emerges in particular social contexts.”
University of Queensland legal academic Patrick Parkinson, said the policy was more balanced, and “recognises the degree of controversy around this subject”.
“One of the emerging issues is how mental health professionals assess the capacity of an adolescent to give an informed consent to cross-sex hormones or surgery, such as a double mastectomy, in circumstances where their capacity may be affected by other mental health problems,” Professor Parkinson said.
“The failure to get a fully informed consent from an adolescent capable of giving that consent is an area of significant medico-legal risk.”
The college in the past endorsed the RCH treatment guidelines – hailed as the “world’s most progressive” by Victoria’s government – and joined the Royal Australasian College of Physicians and trans activist group the Gender Centre in unsuccessfully lobbying for $8m from the NSW government to set up an RCH-style gender affirming network of clinics.
After The Australian reported concerns about the status and rigour of the RCH treatment guidelines in August 2019, the college quietly removed its specific endorsement of the RCH document from its policy on LGBTIQ+ mental health needs.
Asked why it had done this, the college said it would review its policy stance and have a closer look at “the evidence behind the recommendations in the RCH document.”
After a two-year review, the new policy issued on Thursday says the college has decided it will “not preference any specific guidelines”, and simply notes the RCH document in a footnote as one of several guidelines and position statements.
“There’s really no guidance about whether psychiatrists should use those (RCH) guidelines or not,” said Dr D’Angelo.
He said lack of clear advice on was a general fault of the new policy, which seemed an attempt “to navigate a very politically fraught area, trying not to offend any particular interest group”.
RCH gender clinic director Michelle Telfer, who is lead author of her hospital’s treatment guideline, has claimed the document “is accepted as the current gold standard care for Australia and is used as such across the country”.
In its 2019 policy, the college of psychiatrists suggested puberty blocker drugs — used to suppress development of unwanted secondary sex characteristics — were reversible and led to “good outcomes”.
Asked why its new policy is silent on puberty blockers, a spokeswoman for the college pointed to the document’s citation of a review by the UK National Institute for Health and Care Excellence.
In April the NICE review found that the quality of evidence for the effect of these drugs on dysphoria and mental health was “very low”.
The Weekend Australian sought comment from Dr Telfer, RCH and the affirmative gender clinicians lobby AusPATH.
Source: The Australian