Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

Implications of the Cass Review for health policy governing gender medicine for Australian minors

OBJECTIVE

To summarize the key recommendations of England's independent inquiry into gender identity services for children and young people (the Cass Review) and to evaluate their relevance to Australian health policy.

CONCLUSIONS

The Cass Review's findings and recommendations have clear applicability to Australian health policy. As a matter of priority, Australian health authorities need to seriously engage with the Cass Review's findings and recommendations. To not do so will put the health and well-being of vulnerable children and young people at risk.

Gender-affirming care through the lens of abnormal illness behaviour and abnormal treatment behaviour

OBJECTIVE

To describe the increasing number and changing demographics of patients presenting with gender dysphoria and provide an account of patient- and clinician-related factors which may have contributed to these changes. The concept of abnormal illness behaviours introduced by Pilowsky, and its extension to the concept of abnormal treatment behaviours by Singh, provides a framework for understanding healthy and pathological interactions between gender dysphoria patients and their doctors.

CONCLUSIONS

Abnormal illness behaviours driven by the reinforcing contingencies of gender-affirming care may explain, in part, the increasing number and changing demographics of gender dysphoria, as well as the increasing incidence of desistance and detransition. The under-diagnosis and under-treatment of mental health disorders by clinicians treating these patients are examples of abnormal treatment behaviours. Uncritical affirmation of patient reported gender identity appears likely to conceal unconscious motivations of some patients and clinicians, increasing the risks of harm to both.

What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria

The rising incidence of trans youth throughout the world and the new policy of many European countries and 25 US states that psychotherapy should be the first therapeutic response to Gender Dysphoria have made a reexamination of a comprehensive psychiatric evaluation (CPE) urgently relevant. Two conflicting views of the purpose of the CPE exist based on etiologic beliefs and convictions about the best therapeutic approach. This paper provides one clinician's synthesis of the elements, processes, goals, values, benchmarks of CPE and its usual recommendation for psychotherapy. The CPE recommended herein provides cogent hypotheses about the origins of the intrapsychic creation of a trans identity that are to be strengthened, weakened, or supplanted by explanations that emerge from psychotherapy. It also strengthens familial bonds and clarifies the intention to improve the mental health, social function, and autonomy of the minor. The inescapable ethical tensions that surround trans minor health care are discussed. The recommended CPE does not prevent subsequent medical interventions.

Gender-Related Medical Experiences of Youth Who Have Detranstioned

People whose gender does not align with their sex assigned at birth can undergo a medical transition process, so their body reflects their gender. However, some people interrupt this process temporarily or permanently, which is often referred to as "detransition." Media coverage of detrans experiences tend to attribute this phenomenon to a lack of medical gatekeeping. However, research has shown detransitions are highly unpredictable. The aim of this article is to examine the medical experiences of youth who have detransitioned during various stages of the process from transition to today. Twenty-five interviews with 15-25-year-old youth who detransitioned were conducted. Thematic analysis led to the development of six themes: facing gatekeeping and invalidation during transition, accessing trans care, lacking adequate support during transition, finding support in detransition, lacking support in detransition, leaving the medical system. Our results question the usefulness of gatekeeping to prevent detransition and shows that it tends to erode the trust relationship between youth and practitioners and stifle gender exploration. Validation, support, information giving as well as exploration without constrain, or expectation of outcome seems to be a more helpful way forward to work with gender diverse youth.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada

BACKGROUND

Those who detransition have received increased public and scholarly attention and their narratives are often presented as evidence of limitations with contemporary gender-affirming care practices. However, there are scant empirical studies about how this population experienced their own process of gaining access to gender-affirming medical/surgical interventions, or their recommendations for care practice.

AIMS

To qualitatively explore the care experiences and perspectives of individuals who discontinued or reversed their gender transitions (referred to as detransition).

METHODS

Between October 2021-January 2022, Canadian residents aged 18 and older with experience of stopping, shifting, or reversing a gender transition were invited to participate in semi-structured, one-on-one, virtual interviews. A purposive sample of 28 was recruited by circulating study adverts over social media, to clinicians in six urban centres, and within participants' social networks. Interviews ranged between 50-90 minutes, were audio-recorded, and transcribed verbatim. Following constructivist grounded theory methodology, interview data were analyzed inductively and thematically following a two-phase coding process to interpret participants' experiences of, and recommendations for, gender care.

RESULTS

Participants were between the ages of 20-53 (71% were between 20-29). All participants identified along the LGBTQ2S+ spectrum. Twenty-seven out of 28 of the participants received medical/surgical interventions (60% were ages 24 and younger). A majority (57%) reported three or more past gender identities, with 60% shifting from a binary transgender identity at the time of initiating transition to a nonbinary identity later in their transition journey. To access medical/surgical interventions, most participants were assessed via the gender-affirming care model pathway and also engaged in talk therapy with a mental healthcare provider such as a psychologist or psychiatrist. Some participants experienced their care as lacking the opportunity to clarify their individual treatment needs prior to undergoing medical/surgical transition. Decisional regret emerged as a theme alongside dissatisfaction with providers' "informed consent" procedures, such that participants felt they would have benefitted from a more robust discussion of risks/benefits of interventions prior to treatment decision-making. Overall, participants recommended an individualized approach to care that is inclusive of mental healthcare supports.

CONCLUSIONS

To optimize the experiences of people seeking and receiving gender care, a thorough informed consent process inclusive of individualized care options is recommended, as outlined by the World Professional Association of Transgender Health, standards of care, version 8.