Letter to the Editor regarding ‘Re: The RANZCP position statement on gender dysphoria’

To the Editor

We write in response to Zwickl et al.’s (2022) comment on the RANZCP’s (The Royal Australian and New Zealand College of Psychiatrists) position statement (PS) on gender dysphoria. PSs present the College stance on specific issues. The steering group that authored PS 103 met for over 2 years undertaking an extensive review of the literature and going through reviews at multiple committee levels.

From our reading, the conclusions of PS 103 align with the breadth of the literature consulted and the scientific and professional methods employed. Materials considered for inclusion in PSs are evaluated according to the quality of their design and the methodologies employed which provides a hierarchy of reliability through which findings can be interpreted. Not all literature attains a suitable standard for inclusion. For example, the Trans Pathways study identified by Zwickl et al. reported that 21% of young people in that study were unsure if they were intersex. This finding highlights reliability issues in anonymous, self-report, online community survey methodologies, with less than 1% of people actually having a Disorder of sexual development (DSD). Similar methodologies fail to control for a variety of other factors such as involvement in therapy, concurrent use of psychotropic medications and so on, making it erroneous to unequivocally conclude that support and affirmation alone are the ‘protective factors against psychological distress, self-harm and suicidality’.

It is important to note that PS 103 makes no specific reference to transgender people, nor does it pathologise anyone’s lived experiences; it references only individuals experiencing gender dysphoria at levels causing clinically significant distress seeking psychiatric services. Gender dysphoria may be experienced by individuals who do not identify as transgender just as not everyone who identifies as transgender experiences gender dysphoria.

Zwickl et al. regard conclusions of this PS as inappropriate and harmful. They selectively cite literature that purports that medical affirmation alleviates gender dysphoria and improves mental health and quality of life failing to include recent publications and significant changes in international practice that have occurred in recent years. Independent reviews, such as the UK’s National Institute for Health and Care Excellence (2020a,b) identified severe limitations in the evidence for use of puberty blockers and cross-sex hormones in the treatment of gender dysphoria citing the body of research as being of ‘poor quality’ and at ‘high risk of bias’. Other omitted information includes changes to treatment protocols in Finland, Sweden and France favouring the use of psychotherapy and comprehensive assessment over medicalised approaches. Also ignored are the shifting perspectives of World Professional Association for Transgender Health (WPATH) representatives such as Dr Laura Edwards-Leeper, and those with lived experiences, Dr. Marci Bowers and Erica Anderson, WPATH board members who have publicly acknowledged that early puberty blockade can lead to later surgical complications, permanent sexual dysfunction, and the role that peer and social media influences likely contribute to the unprecedented increase in transgender identified adolescent girls.

Zwickl et al. also challenge the phenomena of detransition, minimising its prevalence and significance and ignoring the issue of desistence altogether. Desistence rates are high in childhood onset gender dysphoria with approximately 88% of young people eventually desisting (Singh et al., 2021), many of whom go on to recognise a homosexual sexual orientation. Detransition rates are poorly defined and researched despite gender services opening at an exponential rate in the past decade. The limited research suggests that those who detransition are unlikely to return to previous treatment providers making existing detransition rate estimates a likely underestimation. For example, Littman’s (2021) study of detransitioners identified the most common reason for detransition being the person becoming more comfortable identifying as their natal sex (60%), followed by concerns about potential medical complications from transitioning (49%), unresolved mental health problems (40%) with only 23% identifying external causes such as discrimination. A similar proportion spontaneously identified internalised homophobia as influencing their transition/dysphoria/detransition. Only 24% informed treating clinicians of their discontinued medical treatment.

Furthermore, it is inaccurate for these authors to categorically state that the poor mental health of trans individuals are ‘largely attributable’ to external causes such as discrimination and stigma. Causality cannot be determined by the kinds of research conducted, and it is equally possible that pre-existing mental health vulnerabilities, the presence of a neurodevelopmental disorder such as autism, and prior experiences of trauma unrelated to gendered identity may impact on the development of gender dysphoria in addition to and/or separate from experiences of discrimination and stigma.

In summary, we applaud the RANZCP for having authored a Position Statement on Gender Dysphoria that reflects both rigorous scientific methods and the lived experiences of individuals impacted by gender dysphoria including those who have desisted and detransitioned.