Path to quality of life | A response to Diesel

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As the Professional Association for Transgender Health, South Africa (Pathsa), we would like to respond to “Breaking boundaries safely” (The Witness, August 25) by Alleyn Diesel as we believe it is not an accurate reflection of gender-affirming health care.

Pathsa is an interdisciplinary health professional organisation working to promote the health, wellbeing and self-actualisation of trans and gender diverse people.

READ | Breaking boundaries safely

While we acknowledge that a minority of individuals who accessed gender-affirming health care will detransition and that their stories need to be taken seriously, we assert that this is not the whole picture. Regret is very rare and the majority of people who access gender-affirming health care have a significantly improved quality of life.

The approach to gender-affirming health care is different for prepubertal children, adolescents and adults.

An affirming approach is followed for prepubertal children, which means that instead of attempting to direct a child towards a particular identity, parents and caregivers accept a child’s own individual journey. (Temple Newhook et al., 2018)

Following careful assessment by a qualified mental-health professional, social transition may be recommended. (Durwood et al., 2017) Within this model of care, it is understood that the gender that is the “right fit” may differ at different ages and stages of life.

Research has shown that transgender and gender diverse children who are affirmed in their gender have mental-health outcomes equivalent with cisgender children (whose gender identity and sex assigned at birth are aligned). (Olson et al., 2016)

"The effects of puberty blockers are reversible and when the treatment is stopped, the development of secondary sexual characteristics will continue unless the adolescent is started on hormone treatment."
Dr Elma De Vries

This is in stark contrast to the high levels of psychological distress and behavioural problems documented among children who were discouraged from asserting their identities in childhood. (Turban, 2017)

It can be very distressing for a transgender adolescent to experience the puberty changes in their body, of a gender they do not experience themselves as. In this context, puberty blockers can be used safely to halt the progression of physical changes. Gonadotrophin-releasing hormone agonists (GnRHa) suppress the hormonal axis that results in the secretion of endogenous oestrogen and testosterone responsible for induction of secondary sexual characteristics, such as breast growth and menstruation in trans boys and voice deepening and facial hair development in trans girls. (Telfer et al., 2018)

This permits the adolescent to develop emotionally and cognitively, before making decisions on gender-affirming hormone therapy which is likely to have irreversible effects. Pubertal suppression has been shown to improve mental health and decrease suicidality. (Turban et al., 2020)

The effects of puberty blockers are reversible and when the treatment is stopped, the development of secondary sexual characteristics will continue unless the adolescent is started on hormone treatment.

Follow-up studies after puberty suppression from the Netherlands show that the rate of adolescents who stop the reversible blockers because they no longer wish to transition is very low; between 1,9% (Wiepjes et al., 2018) and 3,5% (Brik et al., 2020) in two respective studies.

For older adolescents, hormone treatment is an internationally accepted option.

Given that this can have potentially irreversible effects, the International Endocrine Society Guidelines recommend initiating treatment after a multidisciplinary team has confirmed gender incongruence and sufficient mental capacity to provide informed consent. (Hembree et al., 2017)

While we agree with Diesel that “hasty and ill-considered diagnoses and treatments” are not in the best interest of anyone, gender-affirming health care that follows a thorough informed consent process can be lifesaving and improves the lives of many transgender and gender diverse people, including in South Africa. The informed consent model of care ensures a process where the risks and benefits of various treatment options are discussed with the adolescent and their parents or legal guardians to enable an informed decision.

The membership of Pathsa includes health professionals who have collectively cared for hundreds of transgender and gender diverse young people, who have better lives as a result.

Diesel uses very distasteful language to describe gender-affirming surgery such as “mutilations” and “a Frankenstein body”. This is an insult to both transgender individuals who access surgery and the surgeons who perform these procedures.

Research has shown that satisfaction following gender-affirming surgery is usually high, with less gender dysphoria, reduced psychological turmoil, and resulting in better integration into society. (Almazan & Keuroghlian, 2021)

"The autonomy of transgender and gender diverse individuals needs to be respected to make choices about their treatment, and our role as health professionals is to facilitate safe access to care. We certainly do not force any individual down a particular path."
Dr Elma de Vries

In contrast to Diesel’s allegation of bodies being “frequently not sexual functioning”, research shows improved sexual functioning following vaginoplasty, with high satisfaction reported for intercourse and orgasm. (Zavlin et al., 2018) Regret following surgery is very low, with a large Dutch cohort reporting regret in 0,6% of trans women and 0,3% of trans men. We would like to clarify that gender-affirming surgery is rarely performed in adolescents. There are cases where a multidisciplinary team will recommend mastectomy for a trans boy with severe chest dysphoria before the age of 18, but that will be following careful consideration that it is indeed in the best interest of the specific individual.

Diesel refers to the principle in medical ethics of “first do no harm”. We would like to point out that withholding gender-affirming treatment is not a neutral act and can indeed be harmful, as South African doctor Anastacia Tomson argues eloquently in an article on gender-affirming care in the context of medical ethics. (Tomson, 2018)

It would be unethical to withhold treatment with a strong evidence base for benefit because of the small percentage of individuals who may later regret their decision and detransition.

The autonomy of transgender and gender diverse individuals needs to be respected to make choices about their treatment, and our role as health professionals is to facilitate safe access to care. We certainly do not force any individual down a particular path.

Although Diesel calls for a more “tolerant world”, she appears not to be tolerant of either health professionals providing gender-affirming health care or transgender and gender diverse individuals who make autonomous decisions to access care.

Pathsa yearns for a world where all transgender and gender diverse people will be respected and accepted as fellow human beings, and be able to access responsible and quality gender-affirming health care.

• Dr Elma de Vries is secretary of the Professional Association for Transgender Health, SA.

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