The role of psychiatrists in working with Trans and Gender Diverse people

Position statement Last updated: Dec 2023 Published in Australia Reference: PS #103

This statement outlines the Royal Australian and New Zealand College of Psychiatrists (RANZCP) position in working with Trans and Gender Diverse (TGD) people in Australia and New Zealand and the role of psychiatrists in responding to their mental health needs.

The RANZCP has developed this position statement to provide the RANZCP’s perspective on the role of psychiatrists in working with TGD people.

The RANZCP stands firmly for respectful discussion regarding TGD care.

This position statement should be read in conjunction with the following documents:

Key messages

The RANZCP acknowledges the evidence (both scientific and historical) that the spectrum of human gender diversity, has long existed in many parts of the world, civilisations, and cultures.
Being Trans or Gender Diverse does not represent a mental health condition.
TGD people experience higher rates of mental illness than the general population. Stigma, discrimination, trauma, abuse, and assault contribute to this mental distress.
Psychiatrists have a responsibility to counter stigma, discrimination and violence directed towards TGD people.
TGD people should be supported with person-centred and non-judgemental care which involves family and whānau where appropriate.
TGD people should have equity of access to health care settings for their general health care needs which must be underpinned by culturally safe practice.
Distress associated with gender may in some situations be related to a range of psychosocial issues or mental health conditions.
Psychiatrists must have regard to the relevant laws and professional standards in relation to assessing capacity and obtaining informed consent, including the RANZCP Code of Ethics.
There are methodological limitations in studies which assess the effectiveness of all models of treatment on the mental health of children and adolescents with Gender Dysphoria. Psychiatric practice will be informed by further emerging evidence.

Terminology and definitions

Trans and Gender Diverse (TGD) people use a range of terms to describe themselves. Consistent with Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population, the RANZCP highlights the importance of using patient-preferred terminology when discussing issues of gender identity, sex, and sexuality with patients who identify as TGD or non-binary.

As language changes rapidly, the RANZCP recommends referring to contemporary terminology guides outlined in the resources section of this position statement.

Sex refers to the biological characteristics that define humans as female or male. While these sets of biological characteristics are not mutually exclusive, as there are individuals who possess both, they differentiate humans as males and females in the vast majority of people.[1]
Gender refers to the state of being male, female, or other, and/or masculine, feminine and other, with regard to personal, social and cultural characteristics, rather than genetic, hormonal or anatomical characteristics.
TGD is an inclusive umbrella term that describes people whose gender does not align with the sex that was registered at birth. This includes people who identify as non-binary.
Gender identity refers to an individual’s personal, internal sense of being, in relation to gender. Gender identity is distinct from chromosomal sex and anatomical sex. Some people have a gender identity which is incongruent with their sex registered at birth.
Gender expression is the way a person expresses their gender identity through their behaviours, mannerisms, clothing, hairstyle, voice, or other characteristics.
Gender Incongruence is defined in the International Classification of Diseases 11th revision (ICD-11), as a ‘marked and persistent incongruence between a person’s experienced gender and assigned sex’.[2]
Gender Dysphoria is defined in the Diagnostic and Statistical Manual of Mental Disorders 5th edition Text Revised (DSM-5-TR) as a ‘marked incongruence between one’s experienced or expressed gender and one’s assigned gender, associated with clinically significant distress or impairment in functioning’.[3]
Conversion therapy refers to a ‘treatment or other practice the purpose, or purported purpose, of which is to change or suppress a person’s sexual orientation or gender identity’.[4, 5] The RANZCP opposes all forms of conversion therapy.

Background

While many TGD people do not need to seek mental health care, there is a higher prevalence of mental health conditions (including depression, suicidality, self-harm, and anxiety) in the TGD population compared to the general population.[6]

Currently the two main psychiatric classification systems differ. The DSM-5-TR diagnoses Gender Dysphoria includes reference to distress/dysfunction (dysphoria) and is categorised as a mental disorder. The ICD-11 references only Gender Incongruence and has reclassified it as a ‘condition related to sexual health’.

Some TGD people seek medical and other treatment to affirm their gender while others do not. Psychiatrists and other health care professionals can have an important role in working with TGD people to achieve their best possible mental health. Often, psychiatrists are consulted by TGD people during very challenging and difficult periods in their lives when they are at their most vulnerable.

The role of psychiatrists in working with TGD people

This position statement provides the RANZCP’s position on the role of psychiatrists in working with TGD people of different ages and in different settings.

In all cases, TGD people should be provided with person-centred, evidence-informed mental health care in a supportive, ethical, non-judgmental, and culturally safe manner should they seek and require it. TGD people have rights to equal access of safe and quality mental health care.

Principles One (psychiatrists shall respect the humanity, dignity, and autonomy of all patients) and Three (psychiatrists shall provide the best attainable care for their patients) of the RANZCP Code of Ethics have particular relevance in working with TGD people. Psychiatrists must also have regard to the relevant laws and professional standards in relation to assessing capacity and obtaining informed consent.

The RANZCP opposes conversion therapy and any other attempts to restrict a person’s gender expression. In all settings, psychiatrists have a duty to ensure the rights and dignity of their patients are protected. Psychotherapy is not conversion therapy. In psychotherapy, the patient’s autonomy and self-determination is respected and the therapist does not impose predetermined notions of gender or sexual orientation on the patient.

Whilst most psychiatrists do not practice in specialist gender clinics, all psychiatrists should be responsive to the mental health needs of TGD people. Multidisciplinary collaboration is important when working with TGD people as their ongoing medical care will often be coordinated within the primary care setting with General Practitioners (GPs).[7] Coordination of care may also be required with other health care professionals including paediatricians, endocrinologists and other health practitioners.

Consistent with Position Statement 105: Cultural safety, the RANZCP highlights the importance of culturally safe practice in all settings to ensure that TGD people receive care that maximises their recovery potential and minimises the risk of negative outcomes or harm to them, along with their family and whānau. The most important goal is to ensure that there is appropriate care available to meet the mental health needs of TGD people, regardless of the setting that they are seen in.

It is essential to ensure that patient confidentiality is respected along with use (written and spoken) of chosen name and pronouns to prevent ‘outing’. TGD people may experience ‘outing’ whereby their gender identity, sexual orientation or biological sex is disclosed without their consent; they may also be deliberately misgendered or experience demeaning language.[8] This may lead an individual to avoid seeking needed health care.[9]

Regardless of any personal beliefs, psychiatrists should always interact with all patients, their families and whānau in a courteous and respectful way. In the case of conscientious objection, it is essential to prevent any negative impact on provision of care with referral to an appropriately skilled clinician who is able to provide timely care.

It is recognised that there is a need to improve training in medical schools and postgraduate medical training regarding transgender health. Many psychiatrists have not had the opportunity to gain specific clinical experience in the health care of TGD people. Psychiatrists should seek continuing professional development (CPD) in this area, including opportunities to hear TGD people speak from their lived experience.

The role of psychiatrists in working with TGD adults

It is important that TGD people are able to access a range of services including psychotherapy and psychosocial support. Therapeutic support over time may provide an opportunity for reflection and exploration. It may offer insights into previously unrecognised contributors to distress, depending on the individual person. Psychotherapy is a patient-led approach and following a thorough assessment can facilitate multiple models of care, without a pre-determined outcome.

Some TGD adults request and undergo gender-affirming medical and/or surgical treatments.[10-13] Psychiatrists can assist the person in making decisions about which treatment approach is most appropriate for them.

Psychiatrists can work with TGD people in a non-judgmental and non-directive therapeutic space to reflect on their gender experience when sought by the individual. In addition, psychosocial support should be available when needed for TGD people, their families, and whānau before, during, and after any gender-affirming treatment, to optimise mental health outcomes.

Cessation of gender-related treatment not through patient choice is usually inappropriate and is highly distressing to the TGD person.[14] Psychiatrists have a responsibility to ensure the safe continuation of established gender-affirming treatment during inpatient care. Established hormonal treatment should not be ceased or changed without discussion with the person and their usual prescribing doctor and GP.

For TGD people in old age psychiatry and residential aged care settings, psychiatrists may advocate for the continuation of longstanding gender-affirming care of a patient who has reduced capacity (e.g., Alzheimer’s dementia).

The role of psychiatrists in working with TGD children and adolescents

For the purpose of this position statement, TGD children and adolescents refers to children and adolescents who present with gender incongruence, which may or may not be associated with resultant distress or dysfunction (gender dysphoria). It also includes those who question, are ambivalent or uncertain about their gender.

Childhood and adolescence are times of rapid and dynamic brain development and development of personal identity. Further, distress in childhood and adolescence is often a consequence of multiple intersecting psychosocial and psychiatric issues. As a result, the clinical care and assessment of TGD children and adolescents can be complex.

Gender expansive and non-conforming behaviour and preferences can be normal at any age and should not necessarily be a cause for concern or require attention. For some people, gender identity and/or gender expression can change over time.

The RANZCP recognises that TGD children and adolescents and their families and whānau have needs and requirements distinct from TGD adults and require developmentally responsive care.

Data demonstrates that TGD children and adolescents are at risk of bullying, discrimination, social exclusion, and physical assault and experience high rates of depression, anxiety, and self-harm.[15]

TGD adolescents have higher rates of suicidal ideation, life-threatening behaviour, self-injurious thoughts or self-harm than their non-TGD peers.[16]

TGD children and adolescents have been reported to experience pervasive stigma and discrimination in health care and difficulty in accessing health care.[17] Many young people also experience internalised transphobia which may cause distress.[17] Children, adolescents and/or their families and whānau who experience distress regarding the young person’s gender identity should have access to mental health care.

TGD children and adolescents need developmentally appropriate and informed care that is person-centred and non-judgmental, which also supports the family and whānau of the young person. Consistent with Position Statement 80: The role of the psychiatrist in Australia and New Zealand, TGD children and adolescents may be seen by psychiatrists in collaboration with other health care professionals (i.e., GPs, paediatricians, endocrinologists, psychologists, social workers and mental health nurses), often in the context of a multidisciplinary team. Psychiatrists should reach out to supports, experts, and multidisciplinary team members as appropriate to support young people.[18]

Psychiatrists can provide a comprehensive assessment and formulation of TGD children and adolescents who present with mental health concerns. They should provide evidence based mental health care for the presenting issue and any comorbid or underlying mental illness experienced by the young person. These interventions may extend to psychosocial interventions (that may include psychotherapy) that is patient-centred and non-directive involving the young person, including family therapy and education for the school to support the young person.

As noted in Position Statement 76: Partnering with carers in mental healthcare and Position Statement 62: Partnering with people with a lived experience, psychiatrists may work in partnership with patients' families, whānau, or carers as they are attuned to the social and cultural factors that impact the experience of the child or adolescent. It is crucial that psychiatrists partner with family and whānau or carers when a child or adolescent experiences distress.

Observational quantitative and qualitative studies inform the care for TGD children and adolescents. There is limited high quality evidence to inform the provision or the withholding of medical interventions for gender affirmation of children and adolescents. Psychiatric practice will be informed by further emerging evidence. The benefits and potential harms of both medical and psychosocial interventions for TGD children and young people have limited evidence.[19]

The risk of intervention needs to be weighed against the risk of non-intervention, in consideration of the individual circumstances. At all times care should be collaborative, and guided by the wishes, values and preferences of the young person and their families and whānau.

Treatments for children and adolescents with Gender Incongruence/Gender Dysphoria, who may identify as Trans or Gender Diverse

If comprehensive psychiatric assessment and treatment for children and adolescents is required, it must occur in accordance with professional standards, and in a way which is person-centred, evidence-informed, and responsive to and supportive of the child or young person’s needs.[20] Psychiatrists should seek further specialist consultation as needed.

Professional opinions differ about some aspects of the most appropriate care for adolescents requesting treatment. A range of interventions (including psychological, social, and medical) may be considered for adolescents presenting with distress related to their gender.[21]

There is a range of recommendations regarding the care of children and adolescents with gender incongruence/gender dysphoria. These include caution on the use of hormonal and surgical treatment, screening for potential coexisting conditions (e.g., ASD and ADHD), arranging appropriate service provision for these conditions, and offering psychosocial support to explore gender identity during the diagnostic assessment.[18] Some TGD young people, supported by their family and whānau, wish for and commence gender-affirming puberty suppression/sex hormone treatment, and report that they experience it as beneficial.[22-27] While a number of major professional organisations support the use of puberty suppressants and cross sex hormones for adolescents [28-30], health authorities in some European countries have recommended restrictions be placed on their use. Australian and New Zealand paediatric services continue to provide multidisciplinary gender-affirming care.[31]

Psychiatrists should remain open and explore the experience and range of support/treatment options that may best address the young person’s needs.[32]

In regard to children and adolescents who experience gender dysphoria or are gender questioning, psychiatrists should consider the young person’s developmental stage, presence of developmental comorbidities (e.g., ASD), and capacity to give informed consent to treatment, in addition to considering the views of their parents/carers.[33]

Young people will have varying levels of autonomy, engagement, involvement, and ownership of their care. There is a need to manage and communicate aspects of care in a manner appropriate for the maturity of the patient. Management and communication of care must be supportive of young people and their families’ and whānau autonomy and independent decision making while also being consistent with legal requirements to ensure safety and reduce risk.[34]

Young people and their family and whānau must be provided with sufficient information to enable them to give informed consent, and understand the potential benefits, risks and unknowns of any treatment being considered.

People who are questioning their gender identity

The RANZCP acknowledges that people who are questioning their gender identity may seek a psychiatrist to navigate and better understand their gender identity. As highlighted in Position Statement 54: Psychotherapy conducted by psychiatrists, psychological intervention such as psychodynamic psychotherapy enables a collaborative and holistic approach to mental health care. Counselling, psychotherapy, and age-appropriate psychoeducation regarding gender development can be beneficial to the wellbeing of people, their family, and whānau who seek understanding of their identity.[14] The goal of psychotherapy, explicit or implicit, is to improve self-awareness and not to promote a particular gender identity outcome.

The role of psychiatrists in working with people who discontinue or reverse prior gender affirming care or ‘detransition’

The RANZCP recognises that some people having commenced gender affirming care, discontinue, pause care or seek reversal of treatment.[35-38]

The term 'detransition' is usually understood to refer to the experience of a person who no longer identifies as transgender, who stops or reverses a gender 'transition'. This process can involve social and legal changes, discontinuation of endocrine medications, surgical intervention to reverse the effects of previous treatments, or varying combinations of the above. This is a heterogenous group and definitions vary. Some individuals prefer the terminology 're-transition', or 'non-linear transition'.

Not every person who stops a gender-affirming treatment has 'detransitioned'. People may discontinue or reverse treatment for a variety of reasons including psychosocial adversity, family opposition, financial circumstances, medical reasons (e.g., in the case of hormone-responsive tumours; to resume fertility).[39] Some continue to identify as transgender. Some people identify with their sex as registered at birth and report that in retrospect they feel that their gender dysphoria was due to other issues (e.g., trauma, internalised homophobia or mental health problems). [35, 38]

It is not known how many individuals who detransition experience regret, and how many are satisfied with the changes they have made. While regret appears to be infrequent [11, 14, 39, 40] the true regret rate is unclear.[14]

Individuals who detransition have been reported to experience mental health concerns including depressive and anxiety disorders [38] and may have difficulty accessing health care services. Some individuals report that they have been harmed by previous gender-affirming care and some have launched legal proceedings against health care providers. Sufficient information should be provided to allow for informed consent for gender-affirming medical and surgical treatments. This should always involve thorough, open discussion of the possibility of disappointment, continued gender dysphoria, regret about irreversible effects of treatment, regret about reduced fertility, and shifts in gender identity or treatment wishes.

Services should also ensure access to care for people who request hormonal or surgical treatment to reverse the effects of previous gender-affirming medical treatment.

When working with people who have discontinued or reverse treatment or have experienced a change in their sense of gender, psychiatrists should provide individualised care, understanding the experience of the patient in a way that fosters a sense of safety. Psychiatrists have a role in helping people who detransition to understand their feelings toward their transition, noting that they may report feelings of grief and loss.[41]

Recommendations

Psychiatrists have a key role to play in the mental healthcare of TGD people.

The RANZCP recommends that:

Psychiatrists should work with TGD people in a way which is person-centred, non-judgmental and is responsive to their mental health needs.
People and their families/whānau should be able to access comprehensive assessment and the opportunity to discuss various pathways of care.
Health services should take steps to accommodate the needs of and ensure the cultural safety of TGD people.
TGD healthcare should be included in training and CPD programs which prepare all health practitioners for practice.
Further research should be supported and funded in relation to wellbeing, quality of life, treatment and outcomes, especially for TGD children and adolescents.
Better access to and consistency of care across Australia and New Zealand for TGD children and adolescents is required, including outcomes monitoring.
The provision of high-quality information, patient education and informed consent processes are essential for trans healthcare across the lifespan.

Resources

Psychiatrists may find the following resources useful. The RANZCP highlights that psychiatrists are responsible for sourcing contemporary resources as research in this field evolves.

References

World Health Organization (WHO). Sexual Health: World Health Organization (WHO); [Available from: https://www.who.int/health-topics/sexual-health#tab=tab_2.
World Health Organization (WHO). International Classification of Diseases, Eleventh Revision (ICD-11)2019.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed., text rev.)2022.
ACT Government. Sexuality and Gender Identity Conversion Practices Act 2020, 2020 [Available from: https://www.legislation.act.gov.au/View/a/2020-49/current/PDF/2020-49.PDF.
Sexual Orientation & Gender Identity Change Efforts Survivors. SOGICE Survivor Statement - Calling for action on the LGBTQA+ conversion movement 2020 [Available from: https://www.sogicesurvivors.com.au/the-statement/.
Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, et al. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry. 2022;34(3-4):292-359.
Crowley D, Cullen W, Van Hout MC. Transgender health care in primary care. Br J Gen Pract. 2021;71(709):377-8.
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Dolan IJ, Strauss P, Winter S, Lin A. Misgendering and experiences of stigma in health care settings for transgender people. Med J Aust. 2020;212(4):150-1.e1.
Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. J Endocr Soc. 2021;5(4):bvab011.
Bustos VP, Bustos SS, Mascaro A, Del Corral G, Forte AJ, Ciudad P, et al. Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery. Plast Reconstr Surg Glob Open. 2021;9(3):e3479.
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022;23(sup1):S1-S259.
Engel L, Majmudar I, Mihalopoulos C, Tollit MA, Pang KC. Assessment of Quality of Life of Transgender and Gender-Diverse Children and Adolescents in Melbourne, Australia, 2017-2020. JAMA Netw Open. 2023;6(2):e2254292.
Marconi E, Monti L, Marfoli A, Kotzalidis GD, Janiri D, Cianfriglia C, et al. A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours. Child and Adolescent Psychiatry and Mental Health. 2023;17(1):110.
Chong LSH, Kerklaan J, Clarke S, Kohn M, Baumgart A, Guha C, et al. Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review. JAMA Pediatrics. 2021;175(11):1159-73.
Telfer MM, Tollit, M.A., Pace, C.C., & Pang, K.C. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.3. Melbourne: The Royal Children's Hospital; 2020.
Watson C DS, Bourke, S, Bourchier L, Temple-Smith M, Sanci L. Evidence for effective interventions for children and young people with gender dysphoria: An Evidence Check rapid review brokered by the Sax Institute for the NSW Ministry of Health. Sax Institute; 2020.
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Thompson L, Sarovic D, Wilson P, Irwin L, Visnitchi D, Sämfjord A, et al. A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment. PLOS Global Public Health. 2023;3(8):e0001478.
Achille C, Taggart T, Eaton NR, Osipoff J, Tafuri K, Lane A, et al. Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology. 2020;2020(1):8.
Allen LR, Watson, L. B., Egan, A. M., & Moser, C. N., Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology. 2019.
Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023;388(3):240-50.
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Pullen Sansfaçon A, Temple-Newhook J, Suerich-Gulick F, Feder S, Lawson ML, Ducharme J, et al. The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics. Int J Transgend. 2019;20(4):371-87.
van der Miesen AIR, Steensma TD, de Vries ALC, Bos H, Popma A. Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. J Adolesc Health. 2020;66(6):699-704.
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MacKinnon KR, Kia H, Salway T, Ashley F, Lacombe-Duncan A, Abramovich A, et al. Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Network Open. 2022;5(7):e2224717-e.
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Vandenbussche E. Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality. 2022;69(9):1602-20.
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Bustos VP, Bustos SS, Mascaro A, Del Corral G, Forte AJ, Ciudad P, et al. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plast Reconstr Surg Glob Open. 2021;9(3):e3477.
Ashley F, Parsa N, kus t, MacKinnon KR. Do gender assessments prevent regret in transgender healthcare? A narrative review. Psychology of Sexual Orientation and Gender Diversity. 2023: No Pagination Specified.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.