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Clayton A, Amos AJ, Spencer J, Clarke P. Implications of the Cass Review for health policy governing gender medicine for Australian minors. Australas Psychiatry 2024:10398562241276335. [PMID: 39216994 DOI: 10.1177/10398562241276335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
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.
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Affiliation(s)
- Alison Clayton
- School of Historical and Philosophical Studies, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew James Amos
- Division of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Jillian Spencer
- Greater Brisbane Clinical school, University of Queensland, Brisbane, QLD, Australia
| | - Patrick Clarke
- Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
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Clarke P, J Amos A. Gender-affirming care through the lens of abnormal illness behaviour and abnormal treatment behaviour. Australas Psychiatry 2024:10398562241276978. [PMID: 39208197 DOI: 10.1177/10398562241276978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
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.
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Affiliation(s)
- Patrick Clarke
- Faculty of Health and Medical Science, Adelaide Health and Medical Sciences building, University of Adelaide, North Adelaide, SA, Australia
| | - Andrew J Amos
- Division of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Wright DA, Giordano S, Pang KC. Further Considerations on Gender-Affirming Care. JAMA Pediatr 2024; 178:841-842. [PMID: 38949839 DOI: 10.1001/jamapediatrics.2024.1866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- Daniel A Wright
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Simona Giordano
- Centre for Social Ethics and Policy (CSEP), Law School, School of Social Sciences, The University of Manchester, Manchester, United Kingdom
| | - Ken C Pang
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Levine SB. What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria. JOURNAL OF SEX & MARITAL THERAPY 2024; 50:773-786. [PMID: 38856025 DOI: 10.1080/0092623x.2024.2362774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
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.
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Affiliation(s)
- Stephen B Levine
- Clinical Professor of Psychiatry, Case Western Reserve University, Cleveland, Ohio, USA
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Gelly MA, Atgé-Delbays S, Gravel É, Sansfaçon AP. Gender-Related Medical Experiences of Youth Who Have Detranstioned. JOURNAL OF HOMOSEXUALITY 2024:1-23. [PMID: 38833642 DOI: 10.1080/00918369.2024.2362268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
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.
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Affiliation(s)
| | | | - Élio Gravel
- School of Social Work, Université de Montréal, Montreal, Canada
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Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1941-1956. [PMID: 38565790 PMCID: PMC11106199 DOI: 10.1007/s10508-024-02850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Sarah C J Jorgensen
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Céline Masson
- Département de Psychologie, Université de Picardie Jules-Verne, Amiens, France
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Sapir L, Littman L, Biggs M. The U.S. Transgender Survey of 2015 Supports Rapid-Onset Gender Dysphoria: Revisiting the "Age of Realization and Disclosure of Gender Identity Among Transgender Adults". ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:863-868. [PMID: 38110845 PMCID: PMC10920421 DOI: 10.1007/s10508-023-02754-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/20/2023] [Accepted: 11/15/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Leor Sapir
- Manhattan Institute for Policy Research, 52 Vanderbilt Ave., New York, NY, 10017, USA.
| | - Lisa Littman
- The Institute for Comprehensive Gender Dysphoria Research, Providence, RI, USA
| | - Michael Biggs
- Department of Sociology, University of Oxford, Oxford, UK
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Skinner SR, McLamore Q, Donaghy O, Stathis S, Moore JK, Nguyen T, Rayner C, Tait R, Anderson J, Pang KC. Recognizing and responding to misleading trans health research. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2024; 25:1-9. [PMID: 38328590 PMCID: PMC10846477 DOI: 10.1080/26895269.2024.2289318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- S. Rachel Skinner
- Department of Adolescent Medicine, Children’s Hospital Westmead, Sydney Children’s Hospitals Network, Westmead, Australia
- Children’s Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | | | - Olivia Donaghy
- Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Psychology, University of Queensland, Brisbane, Australia
| | - Stephen Stathis
- Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Julia K. Moore
- Child and Adolescent Health Service Gender Diversity Service, Perth Children’s Hospital, Perth, Australia
- School of Psychiatry and School of Paediatrics and Child Health, The University of Western Australia, Nedlands, Australia
| | - Tram Nguyen
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
| | - Cate Rayner
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
| | - Robert Tait
- Maple Leaf House, John Hunter Children’s Hospital, Newcastle, Australia
| | | | - Ken C. Pang
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
- Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
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MacKinnon KR, Gould WA, Enxuga G, Kia H, Abramovich A, Lam JSH, Ross LE. Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada. PLoS One 2023; 18:e0293868. [PMID: 38019738 PMCID: PMC10686467 DOI: 10.1371/journal.pone.0293868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Kinnon R. MacKinnon
- School of Social Work, York University, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wren Ariel Gould
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Enxuga
- School of Social Work, York University, Toronto, Ontario, Canada
| | - Hannah Kia
- School of Social Work, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Abramovich
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - June S. H. Lam
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Adult Gender Identity Clinic, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Lori E. Ross
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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