PATHSA responded to an article published in Spotlight, and then in Medical Brief and News24, titled "The Cass Review provides guidance on gender-affirming care: SA’s medical community is now at a crossroads", with this article in Spotlight:
https://www.spotlightnsp.co.za/2024/06/13/why-affirming-treatment-for-gender-questioning-youth-matters-in-sa/
The original version of our response is below.
Healthcare at the Political Crossroads: Why Affirming Treatment for Gender Questioning Youth Matters
The discourse around transgender healthcare, particularly for children and adolescents, has become increasingly contentious. In a recent Spotlight article, First Do No Harm South Africa (FDNHSA) criticised gender-affirming care for young people, raising several concerns that warrant closer examination. As board members of the Professional Association of Transgender Healthcare South Africa (PATHSA), a dedicated interdisciplinary health professional association, we bring extensive experience and expertise in transgender healthcare to this discussion.
FDNHSA asks: ‘will the Cass Review’s call to provide compassionate, evidence-based care to vulnerable children be taken seriously?’
In brief, we say it should be a clarion call for better and more services. The Cass Review, led by Dr Hilary Cass, critically evaluated the UK's Gender Identity Development Service (GIDS), which served trans and gender-diverse (TGD) youth from 1989 until recently. The review identified major operational challenges, such as long waiting lists, inadequate mental health support, and inconsistent treatment protocols. It emphasised the need for individualised care, cautious, evidence-based medical interventions and decentralising transgender healthcare to improve accessibility across the UK.
In South Africa, similar steps are needed to prevent the collapse of gender-affirming care for youth. Currently, we have only one public service providing care for TGD youth at the Red Cross Children’s Hospital’s Division of Child and Adolescent Psychiatry (DCAP). This service assesses TGD youth with their parents or carers and, if appropriate, refers them to paediatric endocrinology at Groote Schuur Hospital for further evaluation and treatment. For those who can afford it, private endocrinologists, psychologists, and other healthcare providers are available. However, only a small handful of paediatric endocrinologists, most of whom are based in Cape Town, work with TGD youth, leaving much of the country and rural areas without health services for TGD youth.
While we support the Cass Review’s broad call for more and better services, we place on record that aspects of the Review have been weaponised, particularly the call for ‘caution’. This has been interpreted as a rejection of puberty suppressants and disapproval of social transitioning. In fact, Dr Cass has distanced herself from earlier controversial statements questioning the benefits of hormone therapy for TGD youth. She clarified that the review did not conclude, despite inaccurate but widely-publicised views to the contrary, that puberty-suppressing hormones are unsafe but recommends making them available at different ages and developmental stages alongside a broader range of gender-affirming healthcare based on individual needs. Other, significant, critiques of the Cass Review exist, particularly of its ideological and methodological underpinnings. The fact that Dr Cass, a senior clinician with no prior involvement in gender affirming care, was selected to lead the review is bewildering. As one senior UK psychiatrist observed, “I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” Suffice to say, it remains a contentious document.
FDNHSA asks: ‘Will the medical societies who have promoted the gender-affirming model revise their position statements and support a less medicalised, more holistic management strategy?’
Gender-affirming care for youth is far more comprehensive than merely prescribing puberty suppressants and hormone therapy without due diligence. FDNHSA misunderstands the term ‘affirmation’ within gender-affirming care, unsurprising given none of its members have worked in TGD youth services.
In gender-affirming healthcare, 'affirmation' means supporting youths' exploration with guidance and understanding, without pushing them towards a predetermined outcome. This holistic approach integrates psychotherapy, informed consent, social support, and medical interventions as needed. It is a multidisciplinary model which involves healthcare professionals, families, and individuals to support informed decision-making that respects self-determination and dignity.
During a meeting with PATHSA and FDNHSA on February 21, 2024, we detailed the rigorous process involved in gender-affirming healthcare. Despite this, FDNHSA provides an oversimplified description of gender-affirming care, detracting from the nuanced, evidence-based approach critical for supporting TGD youth. For example, when this article was republished in Medical Brief, they framed the American Academy of Pediatrics' policy statement, which was named "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents," as “guidance on gender transition” and falsely claims that it was “written by a single doctor.” In reality, Dr Jason Rafferty led the development with contributions from Dr Robert Garofalo and 35 other members and staff from three separate AAP committees, highlighting a collaborative and comprehensive effort. This intentional distortion raises questions about FDNHSA’s integrity and credibility.
FDNHSA asks: ‘Will clinicians who have advocated and implemented medicalising treatment approaches for children and adolescents with gender dysphoria find the humility and courage to change their practise?’
FDNHSA's statement questioning if clinicians will "find the humility and courage to change their practice" is deeply patronising and does not bode well for open and honest dialogue. FDNHSA claim neutrality and present themselves as a voice of reason and objectivity. But their resources webpage reveals anti-trans sentiments. For example, they recommend articles like “The Trans Fad” which dismisses gender identity as a transient phase and undermines the legitimacy of transgender experiences (Fact Checked). FDNHSA promotes an “alternative approach,” based on the “gender exploratory model,” which, ironically, lacks long-term data and evidence. FDNHSA's promotion of, and connections to, anti-trans organisations, such as Genspect, which advocates for severe restrictions on transgender care, are noteworthy. We note that Genspect has officially been declared an anti-LGBTQ+ hate group by the Southern Poverty Law Centre in the United States.
FDNHSA's argument that guidelines should not be written by those who work in gender clinics is nonsensical and overlooks the value of professional experience, as noted above. They are critical of the Southern African HIV Clinicians Society (SAHCS) Gender-Affirming Healthcare Guideline - a comprehensive, context-specific framework developed by 17 healthcare providers and researchers with input from an additional 27 contributors. This is far from the echo chamber FDNHSA implies.
FDNHSA’s approach aims to dismiss as biased the efforts of those who have been advocating for the rights and health of sexually and gender-diverse individuals in South Africa for decades. By contrast, these advocacy efforts are steeped in respect for human rights, are mindful of social prejudice and respect the inherent dignity and autonomy of all[i].
In conclusion
Transgender healthcare for children and adolescents has sparked intense debate globally. As the global north grapples with deep divisions over transgender care, we strive for a different path in South Africa. If the Cass Review, and our own local situation, are to be taken seriously, we need to significantly improve accessibility throughout the country, ensure services are well-resourced, include trained healthcare providers skilled in gender affirming care, and offer comprehensive care that integrates mental health and social services. This calls for a sober and thoughtful approach, not fear-mongering and fruitless attacks on sincere organisations steeped in experience of the field.
We hope transgender healthcare in South Africa becomes less polarised and we remain focused on what is most important. Young trans people matter and deserve holistic care.
The authors are all board members of the Professional Association of Transgender Healthcare South Africa (PATHSA): Rev Chris McLachlan, clinical psychologist; Mx Jenna-Lee de Beer-Procter, clinical psychologist; Dr Robin Dyers, public health specialist; Prof Elma de Vries, family physician; Dr Sakhile Msweli, clinical psychologist; Pierre Brouard, clinical psychologist; Ass. Prof Mershen Pillay, audiologist and speech therapist; Dr Arianne Spitaels, paediatric endocrinologist; Dr Allanah Wilson, psychiatrist; Luh Cele, clinical nurse practitioner. PATHSA is a dedicated interdisciplinary health professional association committed to enhancing the health, well-being, and rights of transgender and gender-diverse individuals in South Africa. Our mission is to advance the understanding, acceptance, and equitable healthcare access for trans communities through education, advocacy, research, and the promotion of best practices. We strongly advocate for, “nothing about us, without us,” and believe that it is imperative for TGD people be included in any debate about their lives and healthcare.
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