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

To the Editor

We appreciate the opportunity to respond to the Letter to the Editor by Clarke and Spiller. Although Clarke and Spiller assert that there were ‘reviews at multiple committee levels’, we – as the two national organisations in transgender healthcare – are unaware of anyone from within our wide networks of experts in, or providers of, mental healthcare to trans people from either Australia or Aotearoa/New Zealand, who were meaningfully consulted about this position statement. Members of the Steering Group have been open around the fact that they did not seek input from those with lived experience internally, owing to a belief that there were no trans members or affiliates with the Royal Australian and New Zealand College of Psychiatrists (RANZCP). This appears to represent a departure from recent RANZCP position statements impacting marginalised populations, which have been developed alongside college members or affiliates with lived experience, those with direct experience of working with a population, and/or community members who are directly impacted by the statements.

Clarke and Spiller describe ‘an extensive literature review’, yet the studies cited in the Position Statement and in their Letter are methodologically flawed and involve very small samples. They use these (Singh et al., 2021 and Littman, 2021) to present highly selective conclusions in an attempt to support their flawed claims of high rates of desistance and detransition. They fail to mention that Singh et al. used data from 139 participants which were collected some 20–30 years ago. Given the tremendous change in societal attitudes, representation, and treatment of trans people in the past two decades, any conclusions of this study must be interpreted with caution.

Meanwhile, Littman’s small study (N = 100) nonsensically states that ‘some detransitioners ... assume (or maintain) a non-binary identification, and some continue to identify as transgender’. This indicates a failure to understand – or an intention to misrepresent – the nuances and diversity of the trans experience. How can someone ‘detransition’ if they continue to identify as non-binary or trans? It appears that Littman considers ‘detransition’ as the cessation or reversal of medical affirmation. However, there is a growing recognition of (so-called) ‘non-linear’ transitions, including short-term or intermittent use of hormones.

There are far larger and more rigorous studies that contradict the conclusions of Singh et al. and Littman. For example, Olson et al. (2022) found that of the 317 children who initiated a binary social transition, only 2.5% were living as cisgender in adulthood. Meanwhile, Wiepjes et al. (2018) demonstrated a gender-affirming surgery regret rate of just 0.5% in a longitudinal study of 6793 trans people between 1972 and 2015. An extensive list of research in support of gender-affirming healthcare has previously been collated and published by AusPATH (2021).

Beyond their reliance on flawed studies to support their position, Clarke and Spiller proceed to attempt to discredit the Trans Pathways study. They suggest that the high prevalence of participants who reported that they were ‘unsure’ whether they were intersex is indicative of reliability issues. However, this has been a common finding within LGBTIQA+ (lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual and many other terms) samples, likely reflecting greater awareness of variations of sex development within the community to which intersex individuals belong (i.e. the I in LGBTIQA+), including a recognition that no individual can definitively say whether they are intersex or not without testing. They go on to suggest that the Trans Pathways methodologies undermine any conclusions about support and affirmation as protective factors. The authors of Trans Pathways have openly acknowledged that it was not a controlled, representative study. However, as the largest survey of trans youth in Australia to date, it has nevertheless been invaluable to our understanding of trans mental wellbeing. Moreover, similar findings have been replicated in numerous independent studies (AusPATH, 2021). Trans Pathways itself has been extensively peer-reviewed, resulting in five publications in highly reputable academic journals, including the Australian and New Zealand Journal of Psychiatry (ANZJP).

Finally, Clarke and Spiller’s scattergun turns to raise findings from international independent reviews which have identified ‘severe limitations in the evidence for use of puberty blockers and cross-sex hormones’. We acknowledge that there have been numerous reviews of the provision of puberty suppression and gender-affirming hormones for minors in the United Kingdom, and that all of these conclude that more research is necessary. We agree with this. However, this inclusion is irrelevant to our article which neither discusses the provision of gender-affirming care in minors or mentions puberty suppression.

In conclusion, contradictory to the RANZCP Position Statement that positioned psychiatrists as central to gender-affirming care, we stand firm on our assertion that treatment of adults pursuing medical gender affirmation should be depathologised, patient-centred and based on an informed consent model of care. There is very strong evidence both in research and in clinical settings that social and medical gender affirmation improve mental health and quality of life, with desistance and detransition being extremely rare.