AusPATH response to Elkadi, J.; Chudleigh, C.;Maguire, A.M.; Ambler, G.R.; Scher,S.; Kozlowska, K. Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study. Children 2023, 10, 314.

Post date:

https://doi.org/10.3390/children10020314

The Australian Professional Association for Trans Health (AusPATH) was established in 2009 and is Australia’s peak body for professionals involved in the health, rights, and wellbeing of all trans people – binary and non-binary. The AusPATH membership comprises over 450 experienced professionals working across Australia.

Elkadi et al (2023) recently published a research paper in the journal ‘Children’, entitled Gender Distress: A Prospective Follow-Up Study (heretofore referred to as “the study”). The AusPATH board and its membership have serious concerns about the misrepresentation of data presented in this research, as well in the choice of language used throughout the paper, which demonstrate a clear agenda of the research team to undermine the provision of gender affirming care to transgender children and adolescents. This response will outline our major concerns with this research article.

AusPATH has concerns about the methodology used and reporting of data in the study. The headline reporting of an “overall desistance rate” of 22.1% of participants does not accurately represent the cohort as, from the authors’ own published data, the following can be seen:

  • Of the young people who presented to the clinic, eleven of those did not meet a diagnosis of Gender Dysphoria and therefore were not offered puberty blockers or gender affirming hormones. As these eleven people should therefore not be included in calculation of “desistance”, the statement in the abstract that ‘the overall desistance rate for gender related distress was 22.1% (17/77)’ is actively misleading.
  • Indeed, using the authors “subgroup of 68 young people who had met DSM-5 criteria for a formal diagnosis of GD (with two lost to follow-up)”, three of the 66 people in the study stopped puberty blockers (4.5%), with one of these young people reaffirming their gender assumed at birth (1.5%). One of the primary goals of puberty suppression is to allow the young person time to decide whether they wish to begin gender affirming hormones. Puberty suppression is completely reversible1,2  and therefore this is not an adverse outcome.
  • Of these 66 people, three people ceased gender affirming hormones (3/66, 4.5%) and this more accurate statistic is not clearly reported. Furthermore, all these participants were considered “desisters”, although none of these participants were known to have reaffirmed the gender assigned to them at birth.  AusPATH considers that these young people are therefore incorrectly labeled as “desisters”. There are many ways to be trans. Seeking gender affirming hormone treatment as part of affirmation is just one. There are myriad reasons that young people may choose to cease gender affirming treatment.3
  • Indeed, the authors of the research have not questioned why their young persons ceased treatment, nor whether the young people regretted accessing treatment. The authors have made statements about people regretting gender affirming medical therapy, leading the reader to believe that people who cease puberty blockers or gender affirming hormones may all regret starting them. Research has shown that not all people who stop treatment reaffirm their gender assigned to them at birth.4 Based on the data presented in the study, only 1.5% (1/66) of the cohort had reaffirmed their gender assigned to them at birth after commencing any stage of treatment. This rate is consistent with other studies,1,2 but this statistic is not highlighted or placed in the context of the wider literature. Instead, the authors focus on a concept of regret, without having demonstrated in their research that these young people regretted treatment.

The authors of the study have stated that they take a “neutral therapeutic stance” when it comes to working with young people on a “transgender pathway”, thereby allowing the reader to believe that their research is neutral in intent. As with previous research released by the authors, the literature cited within this paper is unbalanced, with widely presented opinion throughout the manuscript. There is an abundance of reference to literature that critiques the gender affirming approach, and little reference to the well-described, established, and growing literature demonstrating the mental health and psychosocial benefits of hormonal intervention for this group.2,5 The article is also not aligned with strategies for transgender young people set out by NSW Health;6 the consensus for care within WPATH SOC 8,2 or the RACP position.7 The authors state that gender affirming care is “a treatment that is, in effect “iatrogenic” and a “non-standard risky approach”. The authors go further to credit to the National Association of Practicing Psychiatrists (NAPP) guidelines of care, an organisation with known links to the anti-trans movement and where the current president has provided anti-gender affirming talks to interest groups such as the Australian Christian Lobby. AusPATH calls attention to the fact that the NAPP guidelines endorse an unproven “psychotherapeutic” approach, which was used for decades before being superseded by evidence-based gender-affirming care. Indeed, the denial of gender-affirming treatment under the guise of “exploratory therapy” has caused enormous harm to the trans and gender diverse community and is tantamount to “conversion” or “reparative” therapy under another name.8

The authors use pathologizing and de-humanising language throughout the paper. Rather than using the term “transgender” or “trans” to describe participants, they label trans people as “participants progressing on a [Gender Dysphoria] GD (transgender) pathway”. Gender is a part of identity, and failure to use the accepted language of trans or transgender young people continues to pathologise these young people participating in this research.

The research uses the term “desister” and intentionally broadens the definition of this category to create an inflated figure of those perceived as “detransitioners”, as shown above. One of the current challenges in discussing literature relating to gender affirming care is that there is not yet universal consensus on the terminology used when measuring outcomes that involve cessation of active gender affirming medical treatment (ie. hormonal therapies to affirm gender). The terms “desistance” and “desister” are used in this study to describe participants that, for whatever reason, chose not to continue their medical treatments for gender affirmation. It is important to note that ceasing medical affirmation therapy does not necessarily represent a decision to reaffirm the gender assigned to that person at birth (frequently referred to colloquially and in the literature as “detransitioning”). The choice to cease medical affirmation therapy can represent many things, including for those who are non-binary and decide hormone therapy is not the ideal choice for them at that time; people who choose to take gender affirming hormones for a defined period of time in order to see specific physical effects, beyond which point they no longer feel that those hormones are needed; and those who cease medical treatment due to adverse effects or intolerance of the medications; these reasons should not be conflated with regret or a reaffirmation of the gender assumed at birth. Indeed, by using outdated definitions, referring to only biological males and females with Gender Dysphoria who transition to the other binary gender, without including trans non-binary individuals, the authors have increased the overall number of “desisters” as they have classified any trans non-binary young person who stopped treatment as a “desister” from a “transgender pathway”.

There are several issues with the reporting of mental health in this small sample. The authors make a statement about how one of the underpinning arguments for gender affirming treatment, such as access to puberty blockers and gender affirming hormone treatment, is that research has shown that it alleviates “psychological distress”. The authors then state that the mental health data from their current research are consistent with findings from a Finnish study,9 that showed that those who received gender affirming care showed similar levels of co-occurring mental health concerns before and after treatment. The authors have misrepresented the overall number of people presenting with ‘co-occurring mental health concerns’ in their study to draw this conclusion: rates of life-long conditions such as autism, ADHD and learning disorders will not decrease after gender affirming hormonal treatment and should not be used as markers of “psychological distress”. In fact, the authors data comparing rates recorded on clinical assessment 2013-2018, with reported rates in 2022, showed a decrease in reported rates of anxiety from 66.3% to 44%, and in depression from 62% to 50%. However, we report this apparent improvement with caution as the methodology relies on self-report mental health diagnoses via a telephone call or case note review to determine the rates of mental health issues at follow-up. A more robust and nuanced diagnostic examination of mental health outcomes and symptom profiles should be performed to ensure valid conclusions.

The authors alarmingly included discredited literature around “Rapid Onset Gender Dysphoria” (ROGD) in which they have not only failed to highlight that this research is discredited, but they have gone further to deliberately identify participants in their sample that would “meet” the diagnostic criteria for ROGD. This is not appropriate and reflects the significant bias of the authors. The authors at no point discuss gender diversity as a normal and healthy aspect of human diversity, nor do they recognise that many transgender people experience gender incongruence from childhood or adolescence.2 AusPATH is concerned that the authors are knowingly using terms that are not supported by research and have been deemed as potentially harmful by both AusPATH10 and WPATH.11

Overall, AusPATH is highly concerned by the outdated and offensive language used, the clear biases demonstrated, misrepresentation of data and unfounded conclusions based on this small sample. We firmly support a gender-affirming approach for trans children and adolescents, delivered by a multidisciplinary team, as outlined in the Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents.1

References

  1. Telfer, M.M, Tollit, M.A., Pace, C.C, Y Pang, L.C. Version 1.3, Melbourne: The Royal Children’s Hospital; (2020) Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents.
  2. E. Coleman, A. E. Radix, W. P. Bouman et al. (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23:sup1, S1-S259, DOI:10.1080/26895269.2022.2100644 https://www.wpath.org/soc8
  3. MacKinnon, K.R, et al. (2022) JAMA Network Open. 5(7) Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. DOI: 10.1001/jamanetworkopen.2022.24717
  4. Hall, R., Mitchell, L., & Sachdeva, J. (2021) Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open. 2021;7(6):e184. doi:10.1192/bjo.2021.1022
  5. Australian Professional Association for Trans Health Public Statement on Gender-affirming Healthcare including for Trans Youth. 26 June 2021.  https://auspath.org.au/2021/06/26/auspath-public-statement-on-gender-affirming-healthcare-including-for-trans-youth/  Accessed 28 February 2023.
  6. NSW Ministry of Health (2022). NSW LGBTIQ+ Health Strategy 2022-2027 For people of diverse sexualities and genders, and intersex people, to achieve health outcomes that matter to them https://www.health.nsw.gov.au/lgbtiq-health/Publications/lgbtiq-health-strategy.pdf Accessed 28 February 2022.
  7. https://www.racp.edu.au/docs/default-source/advocacy-library/racp-letter-hon-greg-hunt-minister-for-health-gender-dysphoria-in-children-and-adolescents.pdf Accessed 28th February 2023.
  8. Australian Professional Association for Trans Health Public Statement about the Interim Service Specification for Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) by NHS England 16 November 2022 https://auspath.org.au/2022/11/16/auspath-statement-about-the-interim-service-specification-for-the-specialist-service-for-children-and-young-people-with-gender-dysphoria-phase-1-providers-by-nhs-england/ Accessed 28 February 2023
  9. Kaltiala, R.; Heino, E.; Tyolajarvi, M.; Suomalainen, L. Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nord. J. Psychiatry 2020, 74, 213–219.
  10. Australian Professional Association for Trans Health Public Statement on Rapid Onset Gender Dysphoria 30 September 2019 https://auspath.org.au/2019/09/30/auspath-position-statement-on-rapid-onset-gender-dysphoria-rogd/  Accessed 28 February 2023
  11. World Professional Association for Transgender Health Position Statement on Rapid Onset Gender Dysphoria 4 September 2018 https://www.wpath.org/media/cms/Documents/Public%20Policies/2018/9_Sept/WPATH%20Position%20on%20Rapid-Onset%20Gender%20Dysphoria_9-4-2018.pdf Accessed 28 February 2023.