In 2019 we have already seen a number of important developments in the legislative and mental health sphere with regards to transgender and non-binary people. The Australian Psychological Society continues to contribute to public discussion about the rights of transgender and non-binary people in Australia, and does so from an evidence-based approach. Given the relatively rapid speed at which these changes have occurred, and the nuanced nature of some of the shifts, it is timely to review them. This is especially true given some of the changes have clear and direct implications for psychological research and practice.
The APS and reparative therapy
The APS has made important contributions to the ongoing effort to render so-called ‘reparative therapy’ illegal. In early 2019 it was announced that in Victoria, the current state government intends to draft legislation that will outlaw reparative therapy, including that directed towards transgender and non-binary people. This decision draws upon a significant Australian review on the topic of reparative therapy, and also echoes both the APS statement against reparative therapy in regards to sexuality, and the APS statement on affirming approaches to working with transgender and non-binary people.
What is reparative therapy?
The report Preventing Harm, Promoting Justice emphasises that ‘reparative’ or ‘conversion’ therapies are primarily faith-based approaches to working with gender and sexuality diversity in ways that claim to ‘correct’ both gender and sexuality diversity. Such approaches emphasise the idea that gender and sexuality diversity are sinful and/or pathological. Historically, treatments included psychosurgery and cognitive behavioural approaches using the pairing of visual stimuli with negative consequences, such as shocks or emetic drugs. More recent approaches primarily emphasise spiritual interventions. There is no evidence to suggest that such approaches work in terms of changing a person’s identity, even if in some cases they may change a person’s behaviour. What they do produce, however, are high levels of shame and distress.
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The New South Wales government has commended the Victorian approach, and has indicated that a nationwide approach is necessary to ensure that reparative therapy is no longer practised throughout Australia. We know that such an approach is necessary given that, for transgender and non-binary people, some clinicians and researchers continue to claim that gender diversity can be ‘cured’. The treatment of gender diversity as something to be cured is not a feature of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013) diagnosis of ‘gender dysphoria’, nor as of May 2019 is it a feature of the new revision of the International Classification of Diseases (ICD-11; World Health Organization, 2018) which has moved ‘gender incongruence’ from the mental and behavioural disorders section to the sexual health category.
Importantly, claims to ‘curing’ gender diversity are not the only approaches to transgender and non-binary people that fail to adhere to the directive to adopt affirmative approaches. Most recently, ‘rapid onset gender dysphoria’ has been used to claim, particularly with regard to young people, that being transgender or non-binary is a trend or a phase.
What is rapid onset gender dysphoria?
Rapid onset gender dysphoria (ROGD) is a concept used largely by people who question rather than affirm young people’s gender. The term was developed by parent communities who felt that their children’s disclosure that they were transgender or non-binary was sudden; the claim being that their children had been influenced by peers or by the media. In many ways this account of disclosure frames being transgender or non-binary as a form of social contagion.
While the DSM–5 does make a distinction between early (i.e., in childhood) and late (i.e., in adolescence) disclosure, and notes that the latter may be a surprise to parents, it does not suggest that either earlier or later disclosure are more indicative of the ‘veracity’ of being transgender or non-binary.
To date only one study has examined ROGD, and this drew upon samples from the same parent communities who developed the concept. In other words, it was a biased sample. Since being published, this study has been significantly revised due to community feedback, now indicating more clearly that while certain parents may have views about reasons for disclosure, this is not reflective of a ‘new’ clinical phenomenon (i.e., ROGD). Given the lack of evidence and the founding of the term in communities that may be less than affirming of transgender and non-binary young people, the use of ROGD as a clinical concept or tool would be counter to the APS statement on affirming approaches.
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Both clinicians and researchers should be aware that no professional organisation endorses this pseudo diagnosis, and that organisations such as the World Professional Association for Transgender Health have categorically refuted the use of the term, especially when it is used to create fear or to limit pathways to care.
Gender recognition and marriage
Turning again to recent changes in Australia, Tasmania has introduced laws that no longer require a child’s sex assigned at birth to be listed on their birth certificate. This same legislative change has made it easier for people aged 16 years and older to change their gender marker. Importantly, the legislative change has also removed the requirement that an individual have undertaken gender-affirming surgery in order to change their gender marker. This is a key change as it removes unnecessary restrictions placed on people wanting to affirm their gender legally.
In Western Australia too, an important legislative change has occurred that positively impacts upon transgender and non-binary people. Despite the introduction of marriage equality in Australia in 2017, in some states and territories other legislation that required transgender or non-binary people who were married to divorce before their gender could be legally recognised continued to have a negative impact. Western Australia in 2019 followed other states in removing this requirement.
Where to next?
While legislative change in Tasmania means it is no longer a requirement that people have undertaken gender-affirming surgeries in order to change their gender marker, this is not the case in all Australian states and territories. This is a significant barrier for many transgender and non-binary people, some of whom may not want or be able to afford such surgeries, and others who may have limited access to treatment pathways.
A requirement to undertake gender-affirming surgeries is not simply a barrier to changing one’s gender marker, but can also force people to make significant decisions that may impact upon their fertility. At present the option of fertility preservation is available in varying forms across Australia, though some forms (such as tissue preservation for pre-pubertal children) are not widely available. This has significant implications for the reproductive rights and autonomy of transgender and non-binary people.
“As an evidence-based profession, psychology is very much reliant upon research to direct and guide clinical approaches, but research must in turn be directed and guided by the views and expertise of transgender and non-binary people”
At present, those clinicians and researchers who adopt less than affirming approaches to transgender and non-binary people operate in something of a grey area. This may be particularly true when it comes to young people. Parents may struggle to affirm a transgender and non-binary child and may seek support from clinicians who are less than informed about current best practice. This can result in young people not receiving adequate care, and such young people may have little recourse in terms of complaint mechanisms or alternate forms of support.
Therefore, it is important to consider how the treatment of young people is regulated. In particular, it will be important into the future for affirming treatment teams and gender centres to evaluate when legal action may be required if children are not receiving adequate parental support. This may include hospitals advocating to courts for treatment if it is otherwise being refused by legal guardians (i.e., with regards to puberty suppression). More broadly, it behoves all clinicians as mandated notifiers to consider when less-than-affirming approaches (either on the part of other clinicians or on the part of family members) may constitute forms of neglect, and to make reports as needed to the relevant bodies to ensure that young people receive the affirming clinical care that they need.
Finally, and in regards to research, there have been increasing calls for researchers to be aware of and to adhere to best-practice standards for undertaking research with transgender and non-binary communities. This includes engaging with community members, undertaking community-led research, being aware of the potential implications of certain research topics (especially in terms of the misuse of findings), and the importance of terminology to ensure inclusion. Certainly, as an evidence-based profession, psychology is very much reliant upon research to direct and guide clinical approaches, but research must in turn be directed and guided by the views and expertise of transgender and non-binary people.
In 2019 already, the legislative and clinical mandate for affirming responses to transgender and non-binary people has been strengthened. It is important that, as a profession, we continue to advocate for the needs of transgender and non-binary people. This includes centring the voices of transgender and non-binary people, reflecting on gaps in service provision and research knowledge, and continuing to push for legislative and social change so as to ensure the rights and needs of transgender and non-binary people.
The author can be contacted at [email protected]