Now I’m hopeful we can talk about teens and gender

A new position statement by the Royal Australian and New Zealand College of Psychiatrists wouldn’t ordinarily impact my professional life very much, but I am hopeful that the recent one addressing issues relating to gender non-conforming people will make a difference for healthcare workers beyond the realm of psychiatry.

In acknowledging there are “multiple perspectives and views” about the appropriate clinical approach towards children and teenagers seeking treatment for gender issues, the college offers a chance that Australian health professionals can have an evidence-based and client-centred conversation about the best way to treat and support young people experiencing symptoms of gender dysphoria or gender incongruence.

Can Australian health professionals have a conversation about the best way to support gender non-conforming teens?Credit: Not for syndication

It also provides some hope that Australia can contain a pattern seen elsewhere in the world where health professionals and educators have either been disciplined or lost their jobs for expressing deeply held concerns that the dominant gender-affirming approach causes harm to some young people who report symptoms of gender dysphoria.

It’s an issue I have some first-hand experience with. Earlier this year I was the subject of a formal complaint – my first in 45 years of working as a clinical psychologist. The complaint was brought by a group of people from the transgender community who objected to views I expressed in a podcast for the Australian Psychological Society.

My views were based on my years of clinical education and practice: from the 1970s, I saw clients, until the last 10 years almost always natal male, presenting with gender dysphoria. For most of that time, access to treatment for transition had very strict criteria and was expensive, but the majority of those who did transition were happy with their new lives. In recent years some of my older gender non-conforming clients have finally had access to cross sex hormones and, for some, surgical transition. I felt privileged to be part of this process, which brought relief to them.

But from about 2014, I noticed an increase in natal female between 14 to 20 (so, past puberty), who reported experiencing gender dysphoria and expressed the desire to transition, often asking for support to begin cross-sex hormone therapy. While some described a long history of distress with their bodies, others had only come to the belief in recent months that they experienced gender dysphoria, after learning about it online. In some cases a parent attended a consultation and said this had taken them by surprise as there had been no indications that their child had any confusion about their gender identity.

Two clients in particular were in this second group and concerned me. I wasn’t confident that a diagnosis of gender dysphoria was safe. I noted that these young people typically reported pre-existing mental health problems, particularly a history of anxiety and/or depression, and were socially isolated. It wasn’t until some years later that I became aware that other clinicians held similar concerns, and I came across Lisa Littman’s highly controversial paper on presentations described as rapid onset gender dysphoria, which suggested that social influence was a significant factor in the young person’s belief they were transgender.

My clinical training is to assess and treat each client as an individual, and it is not appropriate to have any preconceived beliefs about a diagnosis until a thorough assessment has been undertaken. I would never try to talk a client out of their beliefs, but I do try to give them permission to explore what pathway is right for them. It is a client-affirming approach. Unfortunately, this approach clashes with the gender-affirming approach that now dominates the socio-political discourse about transgender people, and many health services worldwide.

Broadly, this approach advocates that if a person says they are trans, they are trans, and this should not be questioned. Additionally, if a mental assessment is conducted to determine if the stated symptoms of gender dysphoria are better accounted for by a diagnosis other than being transgender, this may be considered by some activists to be a form of conversion therapy.

And this is where the RANZCP position statement is so significant. It finds “there is some evidence to suggest positive psychosocial outcomes for those who are supported in their gender identity”. But it also acknowledges that “evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate”.

This puts focus directly on the core issue of disagreement among clinicians and from members of the transgender community generally, and allows for much-needed discussion. Although there is agreement across all clinicians working with gender-questioning adolescents that they typically report a history of mental health problems, increasingly some clinicians will consider the possibility that the client has come to the belief they are transgender as a way of providing an explanation for and resolving their pre-existing problems. In my experience, gender-affirming therapists strongly disagree, believing that anything other than immediately affirming the client’s expressed belief they are transgender will compound the harm. My view is that it is precisely because of the high rate of mental health problems in this group that a careful and comprehensive mental health assessment is required as a first step. Shepherding all of these vulnerable young people down the same pathway is poor clinical practice.

As for the complaint against me, the APS took the view that dissenting views to any policy should be heard. The podcast was edited in parts but remains available. In a recent legal decision in Britain, the right of people to express beliefs critical of the theories behind the gender-affirmative approach has been affirmed and anyone with those views is now protected from accusations of discrimination. We need this legal right in Australia.

Dr Sandra Pertot is a clinical psychologist.