MDA National’s policy change to exclude cover for doctors initiating gender affirming hormonal treatment for under 18 year-olds sets a harmful precedent for the future of trans and gender diverse healthcare, and perpetuates the treatment inaccessibility and healthcare inequities currently faced by trans and gender diverse patients.

As such, the Australian Medical Students’ Association (AMSA) has disaffiliated from MDA National until the policy change to exclude medical indemnity cover for practitioners initiating gender affirming hormonal treatment for people under 18 is reviewed and repealed.

Impact of MDA National’s Policy Change

As of July 1st 2023, MDA National has excluded cover for medical indemnity claims that arise out of:

• “A practitioner’s assessment that a patient under the age of 18 years is suitable for gender transition.”
• “A practitioner initiating prescribing of gender affirming hormones for any patient under the age of 18 years.”

AMSA finds MDA National’s policy change to be profoundly harmful as it further entrenches the significant barriers faced by trans, gender diverse and non-binary patients in accessing safe and quality healthcare in Australia.

There is currently a limited number of clinicians able to competently provide gender affirming medical treatments. By refusing to protect these clinicians, this policy change directly obstructs and minimises healthcare opportunities that trans and gender-diverse people can access. This lack of access is compounded by intersections such as rurality and remoteness, widening the healthcare disparity for trans and gender diverse people living outside urban areas who already experience reduced access to care.

Expecting young trans and gender diverse patients to solely rely on hospital clinics for gender affirming treatment means that patients will remain on long waitlists for years. All people deserve access to quality primary and secondary care in the community.

What Has Informed Our Stance

MDA National's policy change rescinding cover for gender-affirming care is based upon the risk of liability for doctors in cases of “transition regret”’.

However, AusPATH President Professor Ashleigh Lin states that “recent scientific findings demonstrate that the rate of “regret” following gender-affirming medical intervention is very low. (1-8) This includes a meta-analysis of several thousand surgical cases showing a rate of “regret” from surgery of less than 1%,(1) a significantly lower rate of regret than many other common procedures.”

“Transition regret” and re/detransition are not synonymous. A person may detransition without regret, or may regret an aspect of their care whilst still living as a trans person. The idea of unidirectional, fixed gender transition is profoundly cisnormative, misunderstands the fluidity of gender throughout the life-course, and erases the experience of non-binary peoples.

Reasons for “transition regret” are diverse, and may not represent a desire that the transition was not attempted at all. As evidenced in pertinent medico-legal literature, when doctors have provided supportive care according to informed consent models, previous case law, legislation, policy and community authored guidelines, they can be assured they have provided the best management possible. (2,5, 9-13)

AMSA’s Stance

AMSA stands against the rescinding of insurance cover for gender affirming hormone treatment for children and adolescents. We emphasise, based upon high quality evidence and an orientation towards rights-based medical care, that all safe gender affirming treatment should be covered by indemnity insurers.

We are accountable to our members through our policy base which is voted upon by representatives from all Australian medical schools. AMSA stands very clearly in support of the informed consent model of gender affirming care. In particular, our LGBTQIASB+ Health Policy (2023) calls upon:(14)

• 1ci) The Australian Government to uphold the rights of LGBTQIASB+ peoples using Medicare by recognising gender-affirming surgery and other forms of genderaffirming care as essential medical care that must be subsidised;
• 6c) Indemnity insurers to ensure that provision of care specific to LGBTQIASB+ peoples, including young peoples, is covered under their policies.

AMSA has completed an extensive consultation process with expert clinicians practising gender-affirming care across the country, who have unequivocally affirmed AMSA’s stance.

As the peak representative body for Australia’s future doctors, AMSA stands in solidarity with transgender and gender-diverse communities. It is our duty to the future of medicine to fight back against the perpetuation of transphobia and subsequent poor health provision for these communities within our medical system.

References

1. 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.
2. Turban JL, Brady C, Olson-Kennedy J. Understanding and Supporting Patients With Dynamic Desires for Gender-Affirming Medical Interventions. JAMA Network Open. 2022;5(7):e2224722-e.
3. Narayan SK, Hontscharuk R, Danker S, Guerriero J, Carter A, Blasdel G, et al. Guiding the conversationtypes of regret after gender-affirming surgery and their associated etiologies. Ann Transl Med. 2021;9(7):605.
4. Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health. 2021;8(4):27380.
5. MacKinnon KR, Ashley F, Kia H, Lam JSH, Krakowsky Y, Ross LE. Preventing transition “regret”: An institutional ethnography of gender-affirming medical care assessment practices in Canada. Social Science & Medicine. 2021;291:114477.
6. Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018;15(4):582-90.
7. Leibowitz S, Green J, Massey R, Boleware AM, Ehrensaft D, Francis W, et al. Statement in response to calls for banning evidence-based supportive health interventions for transgender and gender diverse youth. International Journal of Transgender Health. 2020;21(1):111-2.
8. Sansfaçon AP, 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. International Journal of Transgenderism. 2019;20(4):371-87.
9. Parliament of South Australia. Consent to Medical Treatment and Palliative Care Act 1995 [Internet]. Jan 31, 2023. Available from: https://www.legislation.sa.gov.au/__legislation/lz/c/a/consent%20to%20medical%20treatment%20and%2 0palliative%20care%20act%201995/current/1995.26.auth.pdf
10. NSW Ministry of Health. Consent to Medical and Healthcare Treatment Manual [Internet]. NSW: NSW Goverment; 2020 Feb [cited 2023 Jul 1] p. 1–82. Available from: https://www.health.nsw.gov.au/policies/manuals/Publications/consent-manual.pdf
11. Boddice J. Re A [Internet]. Family Court of Australia. Vol. QSC 159. 2022 [cited 2023 Jul 1]. Available from: https://www.queenslandjudgments.com.au/caselaw/qsc/2022/159/pdf
12. Thackray, Strickland, Ainslie-Wallace, Ryan, Murphy. Re Kelvin [Internet]. Family Court of Australia. Vol. 258. 2017 [cited 2023 Jul 1]. Available from: https://humanrights.gov.au/sites/default/files/Re%2BKelvin%2B30%2BNovember%2B2017.pdf
13. Bryant, Finn, Strickland. Re Jaime. Family Court of Australia. Vol. 110. 2013 [cited 2023 Jul 1].
14. Australian Medical Students’ Association. LGBTQIASB+ Health [Internet]. Australian Medical Students’ Association: 2023 [cited 7 July 2023]. Available from: https://amsa.org.au/wp-content/uploads/2023/10/LGBTQIASBplus-Health-2023.pdf