Re: Updated position statement on gender dysphoria

As a transgender trainee within the college, the updated Position Statement 103 ‘Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence’ left me feeling ashamed to be entering the specialty.

Our stated vision is ‘To enhance the mental health of our nations through leadership in high-quality psychiatric care’ and this update represents neither leadership nor high-quality care. The absence of gender-diverse voices within the group is apparent and as such the contribution of those with personal experience (Position Statement 85) is not valued. We recognise and accept the depsychopathologisation of gender diversity. Yet – through framing this as something which may require psychiatric assessment by default – we continue to assert the disingenuous position of the psychiatrist being the ‘gatekeeper’ to treatment, thus undermining the depathologisation and perpetuating stigma. This is in spite of viable alternative and co-designed models placing the general practitioner (GP) at the centre of care (Health Quality and Safety Commission of New Zealand [HQSCNZ], 2019), with psychiatry as an adjuvant for those experiencing psychological distress or having other mental health concerns. This is in addition to continuing to perpetuate an idea that particular subspecialty expertise is required to assist those with gender diversity, which has been well evidenced to contribute to difficulties this population face in accessing appropriate care – psychiatric or otherwise.

We take the definition of gender-affirming care from Hidalgo et al. (2013) ‘live in the gender that feels most real or comfortable to that child and to express that gender with freedom from restriction, aspersion, or rejection’ out of its original context, and instead add a narrowed interpretation that ‘therefore the child’s statements regarding their gender identity should not be questioned, but instead accepted’.

In this, we misrepresent gender-affirming care as “not [to] be questioned”, when the opposite is true. We should encourage the individual to question, explore and come to their own conclusion. The key is not presupposing an outcome, but instead supporting this journey. We facilitate access to treatments and interventions chosen by the individual, as opposed to taking a conveyer-belt or one-size-fits-all approach to gender-affirmation. It is sharing of knowledge and empowerment of the individual to see possibilities, rather than a paternalistic charting to an assigned gender. This may result in a new gender identification or may lead to better comfort in one’s original gender. Both are valid outcomes.

We acknowledge the high rates of mental distress in gender-diverse individuals, however downplay evidence supporting gender-affirming care. This includes improved mental health after, for example, gender-affirming hormone treatment (Nguyen et al., 2018) or assuming a chosen name (Pollitt et al., 2019). Other studies show reduced utilisation of mental health services post gender-affirmation (Bränström and Pachankis, 2020). Instead, we emphasise ‘real life experience’ (RLE) which has been considered psychologically demeaning and disempowering when coupled with gatekeeping (Pearce, 2018). We justify this inclusion by citing what would now be considered the Fifth Version of the World Professional Association for Transgender Health (WPATH) Standards of Care from 1999. Of note is that we are awaiting the release of the Eighth Version later this year and that RLE has not been included in the editions between for the aforementioned reasons. As such, this does not reflect up-to-date (or ethical) practice.

With this statement, we had an opportunity to step up and advocate for a vulnerable community. We have failed to do so, and so in our duty as advocates and leaders in psychiatric care.