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Statements

American Academy of Child and Adolescent Psychiatry

Sexual Orientation, Gender Identity, and Civil Rights

"The American Academy of Child & Adolescent Psychiatry rejects all public and private discrimination based on sexual orientation or gender identity of persons of any age particularly in the areas of employment, military service, housing, public accommodations, membership, licensing, promotion or assignment, education, training, marriage, adoption, parenting, foster care, or qualification as an expert in a court of law. The AACAP affirms the right of all people to their orientation and identity without interference or coercive interventions attempting to change sexual orientation or gender identity.

"Further, the AACAP condemns any restriction on employment or service based on sexual orientation or gender identity in positions involving the delivery of services or treatments to children and adolescents."[1]

Gay, Lesbian, Bisexual, or Transgender Parents

"All decisions relating to custody and parental rights should rest on the interest of the child. There is no evidence to suggest or support that parents who are lesbian, gay, bisexual, or transgender are per se superior or inferior from or deficient in parenting skills, child-centered concerns, and parent-child attachments when compared with heterosexual parents. There is no credible evidence that shows that a parent's sexual orientation or gender identity will adversely affect the development of the child.

"Lesbian, gay, bisexual, or transgender individuals historically have faced more rigorous scrutiny than heterosexual people regarding their rights to be or become parents. The American Academy of Child & Adolescent Psychiatry opposes any discrimination based on sexual orientation or gender identity against individuals in regard to their rights as custodial, foster, or adoptive parents."[2]

Transgender Youth in Juvenile Justice and other Correctional Systems

"Research demonstrates that transgender youth are at increased risk for being bullied, harassed and physically assaulted. They also have a higher incidence of suicide attempts. For these reasons, transgender youth face particular challenges in juvenile justice and other correctional systems.

"The American Academy of Child and Adolescent Psychiatry opposes all discrimination based on gender identity. Consistent with this position, the Academy recommends that detention and corrections staff classify and house all youth consistent with their gender identity, as the youth defines it. Based on individualized risk assessments, facilities should take the necessary precautions to ensure the safety of every youth in their custody, including transgender youth.

"The Academy further recommends that transgender youth should be referred to by their preferred pronoun and name. The Academy also believes that transgender youth must have access to all educational and recreational programs and services available to the general youth population. Absent serious short term safety concerns, it is inappropriate, discriminatory and dangerous for transgender youth to be segregated, isolated or placed in solitary confinement due to resource limitations or the absence of an appropriate setting. Finally, the Academy believes that transgender youth in correctional systems are entitled to access to comprehensive psychiatric and other medical care consistent with prevailing national standards and guidelines."[3]

American College of Obstetricians and Gynecologists

"Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder."[4]

American Medical Association

  • "Whereas, The American Medical Association opposes discrimination on the basis of gender identity and
  • "Whereas, Gender Identity Disorder (GID) is a serious medical condition recognized as such in both the Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision) (DSM-IV-TR) and the International Classification of Diseases (10th Revision), and is characterized in the DSM-IV-TR as a persistent discomfort with one's assigned sex and with one's primary and secondary sex characteristics, which causes intense emotional pain and suffering; and
  • "Whereas, GID, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death; and
  • "Whereas, The World Professional Association For Transgender Health, Inc. ("WPATH") is the leading international, interdisciplinary professional organization devoted to the understanding and treatment of gender identity disorders,and has established internationally accepted Standards of Care for providing medical treatment for people with GID, including mental health care, hormone therapy and sex reassignment surgery, which are designed to promote the health and welfare of persons with GID and are recognized within the medical community to be the standard of care for treating peoplewith GID; and
  • "Whereas, An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID; and
  • "Whereas, Health experts in GID, including WPATH, have rejected the myth that such treatments are "cosmetic" or "experimental" and have recognized that these treatments can provide safe and effective treatment for a serious health condition; and
  • "Whereas, Physicians treating persons with GID must be able to provide the correct treatment necessary for a patient in order to achieve genuine and lasting comfort with his or her gender, based on the person's individual needs and medical history; and
  • "Whereas, The AMA opposes limitations placed on patient care by third-party payers when such care is based upon sound scientific evidence and sound medical opinion; and
  • "Whereas, Many health insurance plans categorically exclude coverage of mental health, medical, and surgical treatments for GID, even though many of these same treatments, such as psychotherapy, hormone therapy, breast augmentation and removal, hysterectomy, oophorectomy, orchiectomy, and salpingectomy, are often covered for other medical conditions; and
  • "Whereas, The denial of these otherwise covered benefits for patients suffering from GID represents discrimination based solely on a patient's gender identity; and
  • "Whereas, Delaying treatment for GID can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illnesses, depression, and substance abuse problems, which further endanger patients’ health and strain the health care system; therefore be it RESOLVED, That the AMA support public and private health insurance coverage for treatment of gender identity disorder (Directive to Take Action); and be it further RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician(Directive to Take Action)."[5]

American Psychiatric Association

"American Psychiatric Association, Position Statement on Access to Care for Transgender and Gender Variant Individuals Approved by the Board of Trustees, July 2012 Approved by the Assembly, May 2012 Policy documents are approved by the APA Assembly and Board of Trustees...These are...position statements that define APA official policy on specific subjects..." –APA Operations Manual

"Transgender and gender variant individuals currently lack access to the best standards of clinical practice, frequently do not have the opportunity to pursue patient-focused treatment decisions, do not receive scientifically established treatment and could benefit significantly from APA's advocacy."

"APA Position:

"Therefore, the American Psychiatric Association:

  1. "Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
  2. "Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
  3. "Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician."[6]

American Psychological Association

  • "APA opposes all public and private discrimination on the basis of actual or perceived gender identity and expression and urges the repeal of discriminatory laws and policies
  • "APA supports the passage of laws and policies protecting the rights, legal benefits, and privileges of people of all gender identities and expressions
  • "APA supports full access to employment, housing, and education regardless of gender identity and expression
  • "APA calls upon psychologists in their professional roles to provide appropriate, nondiscriminatory treatment to transgender and gender variant individuals and encourages psychologists to take a leadership role in working against discrimination towards transgender and gender variant individuals
  • "APA encourages legal and social recognition of transgender individuals consistent with their gender identity and expression, including access to identity documents consistent with their gender identity and expression which do not involuntarily disclose their status as transgender for transgender people who permanently socially transition to another gender role
  • "APA supports access to civil marriage and all its attendant benefits, rights, privileges and responsibilities, regardless of gender identity or expression
  • "APA supports efforts to provide fair and safe environments for gender variant and transgender people in institutional settings such as supportive living environments, long-term care facilities, nursing homes, treatment facilities, and shelters, as well as custodial settings such as prisons and jails
  • "APA supports efforts to provide safe and secure educational environments, at all levels of education, as well as foster care environments and juvenile justice programs, that promote an understanding and acceptance of self and in which all youths, including youth of all gender identities and expressions, may be free from discrimination, harassment, violence, and abuse
  • "APA supports the provision of adequate and necessary mental and medical health care treatment for transgender and gender variant individuals;
  • "APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments;
  • "APA supports access to appropriate treatment in institutional settings for people of all gender identities and expressions; including access to appropriate health care services including gender transition therapies;
  • "APA supports the creation of educational resources for all psychologists in working with individuals who are gender variant and transgender;
  • "APA supports the funding of basic and applied research concerning gender expression and gender identity;
  • "APA supports the creation of scientific and educational resources that inform public discussion about gender identity and gender expression to promote public policy development, and societal and familial attitudes and behaviors that affirm the dignity and rights of all individuals regardless of gender identity or gender expression;
  • "APA supports cooperation with other organizations in efforts to accomplish these ends.[7]

Royal College of Psychiatrists

Position Statement on supporting transgender and gender-diverse people

Purpose of the document

"This Position Statement:

  • "sets out the Royal College of Psychiatrists’ view on how to work with transgender and gender-diverse people if they seek mental health services
  • "makes recommendations on how this can be best implemented."

"This statement is concerned with the general approach by psychiatrists and does not cover the detail of current psychiatric and medical treatments for transition."

Issues

Gender

"Transgender and gender-diverse people are individuals whose gender identity and/or gender role do not conform to the sex assigned to them at birth. While the term ‘transgender’ is commonly accepted, not all gender-diverse people self identify as transgender, or with the binary concept of gender that is common to most cultures (Bouman et al., 2017; Richards et al., 2016; Saewye et al., 2017). For most of the history of psychiatric practice, transgender and gender-diverse individuals have been considered to have a psychiatric diagnosis. ‘Gender identity disorder’ is the umbrella term used in the 10th edition of the International Classification of Diseases (ICD; WHO, 1992) although it is expected that the 11th edition will adopt the new term "gender incongruence" and remove this from the mental disorders chapter, hence de-classifying being trans as a mental disorder (Drescher et al., 2012). Field testing of these proposals has been positively received (Beek et al., 2016). Supporting transgender and gender-diverse people: PS02/18 3 Gender identity disorder was also the term used in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV; APA, 1994) but in the current edition of the DSM (DSM-5; APA, 2013) the term ‘gender dysphoria’ is used."

Conversion Therapies

"Over the twentieth century, talking therapies and medical treatments emerged that tried to make homosexual or bisexual people, heterosexual. These so-called conversion therapies have no scientific basis and have been shown to be harmful in this context in many countries around the world, including the United Kingdom (MoU). The term ‘conversion therapy’ has also been used to describe treatments for transgender people that aim to suppress or divert their gender identity – i.e. to make them cisgender – that is exclusively identified with the sex assigned to them at birth. Conversion therapies may draw from treatment principles established for other purposes, for example psychoanalytic or behaviour therapy. They may include barriers to gender-affirming medical and psychological treatments. There is no scientific support for use of treatments in such a way and such applications are widely regarded as unacceptable."

Evidence

"Psychiatric disorders (particularly anxiety, depression and acts of self-harm) in treatment-seeking transgender people are much more common than in cisgender people (Arcelus et al., 2016; Bouman et al., 2017). There is evidence that this increased rate of psychiatric disorders can, in part, be explained by societal responses to transgender people. For example, pupils who present as transgender or gender-diverse are also disproportionately affected by bullying in schools (Bradlow et al. 2017) and are therefore at higher risk of experiencing poor mental health, particularly self-harm and suicide attempts. Regardless of cause, it is essential that transgender people can seek help in confidence for such psychological distress or illness. While gender-affirming medical interventions improve, wellbeing and mental health in transgender and gender diverse adults (Dhejne et al., 2016), more evidence is needed on management of gender-diverse children, particularly those who are pre-pubertal. This includes understanding how gender dysphoria in childhood continues into adolescence, as well as the impact of interventions to begin the process of transition in very young gender diverse people. Supporting transgender and gender-diverse people: PS02/18 4 (Olson-Kennedy et al., 2016). Long-term follow-up studies of young transgender people are needed. The extent of use of conversion therapies with transgender people is unclear. Published papers on conversion therapies in lesbian, gay and bisexual people do not always state whether or not transgender and gender-diverse people are included (Mizock & Lewis, 2008). A review of academic publications has recently been completed and submitted for publication (Wright et al., 2018). The findings suggest that specific treatments to persuade transgender and gender-diverse people to accept their gender as assigned at birth are rare, but there is evidence of barriers to transgender people receiving appropriate help to enable medical and social transition. Denying access to genderaffirming treatment is likely to have a detrimental effect on the wellbeing of transgender and gender-diverse people."

The College position

"The College supports psychiatrists in fully exploring their patient's gender identity (involving their families where appropriate) in a nonjudgemental, supportive and ethical manner. The College acknowledges the need for better evidence on the outcomes of pre-pubertal children who present as transgender or gender-diverse, whether or not they enter treatment. Until that evidence is available, the College believes that a watch and wait policy, which does not place any pressure on children to live or behave in accordance with their sex assigned at birth or to move rapidly to gender transition, may be an appropriate course of action when young people first present. The College is committed to working with people who seek help in the context of gender diversity. It considers that interventions that claim to convert transgender and gender-diverse people into cisgender people are without scientific foundation and thus both unethical and unacceptable. Thus, the College concurs with the views of many international professional organisations, such as the World Professional Association for Transgender Health (WPATH), the American Academy of Child & Adolescent Psychiatry, and the American Psychological Association, that psychological treatments to suppress or ‘revert’ gender-diverse behaviours are unscientific and unethical. The Royal College of Psychiatrists considers that use of conversion therapy with transgender and gender diverse (or lesbian, gay or bisexual) people may be an act of discrimination under the Equality Act (2010). Supporting transgender and gender-diverse people: PS02/18 5"

Recommendations for action

  • "The Royal College of Psychiatrists, as well as medical schools, through their responsibilities for training of doctors and psychiatrists, should promote the need for competence in supporting the wellbeing of transgender and gender diverse people and clarity that gender diversity per se is not a disorder.
  • "The Royal College of Psychiatrists should continue to provide professional education events on appropriate care and treatment when patients are transgender or gender-diverse.
  • "The National Institute for Health Research and other UK grant funding bodies should commission research to increase our understanding of psychiatry's role in treatments for transgender youth, particularly very young gender-diverse people, to ensure that they fulfil their potential in comfort.
  • "The Department of Health and Social Care and the Department for Education should ensure all schools provide appropriate staff training and have clear policies that support transgender children. These include tackling bullying, effective safeguarding, parental concerns, and practical considerations (such as appropriate language, use of toilets and changing rooms, and uniforms).
  • "The Royal College of Psychiatrists should work closely with other international organisations in order to improve the wellbeing of transgender and gender diverse people.
  • "The College recommends that the WHO International Classification of Diseases (ICD) and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) should, at the earliest opportunity, de-classify any terms they use to describe transgender as a mental health disorder.[8]

World Psychiatric Association

WPA Position Statement on Gender Identity and Same-Sex Orientation, Attraction, and Behaviours

Background

"Recent controversies in many countries suggest a need for clarity on same-sex orientation, attraction, and behaviour (formerly referred to as homosexuality).

"Along with other international organisations, World Psychiatric Association (WPA) considers sexual orientation to be innate and determined by biological, psychological, developmental, and social factors.

"Over 50 years ago, Kinsey et al. (1948) documented a diversity of sexual behaviours among people. Surprisingly for the time, he described that for over 10% of individuals this included same-sex sexual behaviours. Subsequent population research has demonstrated approximately 4% of people identify with a same-sex sexual orientation (e.g., gay, lesbian, and bisexual orientations). Another 0.5% identify with a gender identity other than the gender assigned at birth (e.g., transgender) (Gates 2011). Globally, this equates to over 250 million individuals.

"Psychiatrists have a social responsibility to advocate for a reduction in social inequalities for all individuals, including inequalities related to gender identity and sexual orientation.

"Despite an unfortunate history of perpetuating stigma and discrimination, it has been decades since modern medicine abandoned pathologising same-sex orientation and behaviour (APA 1980) The World Health Organization (WHO) accepts same-sex orientation as a normal variant of human sexuality (WHO 1992). The United Nations Human Rights Council (2012) values Lesbian Gay Bisexual and Transgender (LGBT) rights. In two major diagnostic and classification systems (International Classification of Diseases (ICD-10) and DSM-5), same sex sexual orientation, attraction, and behaviour and gender identity are not seen as pathologies (WHO 1993, APA 2013).

"There is considerable research evidence to suggest that sexual behaviours and sexual fluidity depend upon a number of factors (Ventriglio et al 2016). Furthermore, it has been shown conclusively that LGBT individuals show higher than expected rates of psychiatric disorders (Levounis et al 2012, Kalra et al 2015), and once their rights and equality are recognised these rates start to drop (Gonzales 2014, Hatzenbuehler et al 2009, 2012, Padula et al 2015)

"People with diverse sexual orientations and gender identities may have grounds for exploring therapeutic options to help them live more comfortably, reduce distress, cope with structural discrimination, and develop a greater degree of acceptance of their sexual orientation or gender identity. Such principles apply to any individual who experiences distress relating to an aspect of their identity, including heterosexual individuals.

"WPA believes strongly in evidence-based treatment. There is no sound scientific evidence that innate sexual orientation can be changed. Furthermore, so-called treatments of homosexuality can create a setting in which prejudice and discrimination flourish, and they can be potentially harmful (Rao and Jacob 2012). The provision of any intervention purporting to "treat" something that is not a disorder is wholly unethical."

Action

  1. "The World Psychiatric Association (WPA) holds the view that lesbian, gay, bisexual, and transgender individuals are and should be regarded as valued members of society, who have exactly the same rights and responsibilities as all other citizens. This includes equal access to healthcare and the rights and responsibilities that go along with living in a civilised society.
  2. "WPA recognises the universality of same-sex expression, across cultures. It holds the position that a same-sex sexual orientation per se does not imply objective psychological dysfunction or impairment in judgement, stability, or vocational capabilities.
  3. "WPA considers same-sex attraction, orientation, and behaviour as normal variants of human sexuality. It recognises the multi-factorial causation of human sexuality, orientation, behaviour, and lifestyle. It acknowledges the lack of scientific efficacy of treatments that attempt to change sexual orientation and highlights the harm and adverse effects of such "therapies".
  4. "WPA acknowledges the social stigma and consequent discrimination of people with same-sex sexual orientation and transgender gender identity. It recognises that the difficulties they face are a significant cause of their distress and calls for the provision of adequate mental health support.
  5. "WPA supports the need to de-criminalise same–sex sexual orientation and behaviour and transgender gender identity, and to recognise LGBT rights to include human, civil, and political rights. It also supports anti-bullying legislation; anti-discrimination student, employment, and housing laws; immigration equality; equal age of consent laws; and hate crime laws providing enhanced criminal penalties for prejudice-motivated violence against LGBT people.
  6. "WPA emphasises the need for research on and the development of evidence-based medical and social interventions that support the mental health of lesbian, gay, bisexual, and transgender individuals.[9]

References

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