So welcome to the second episode of the Thought Broadcast with Zoe Christensen and Theo McTeague. In our first episode, we discussed training issues that are faced by gender-diverse people in our training community. And then in our second discussion at Congress 2022, we focused in more on the topics raised in Zoe's discussion or talk, sorry, at the Congress and different ways that we can improve the culture of the college moving forward for gender-diverse people. My name is Oliver Robertson. I'm the trainer editor of Australasian Psychiatry, and I go by he, him pronouns, and I'll introduce my co-host Michael Waiteman.

Hi Ollie. Yeah, pleased to be here, and I also use he, him as my pronouns.

That's good. And thank you, Zoe, for joining us today.

Thanks for having us, Mark. I'm Zoe. I still use she, her, and I pronouns.

And thank you, Theo.

Hi, thanks so much for having me also. Um I'm Theo, I go by Vay Vem.

So I suppose, Zoe, from your experience, you you are trans and you are a psychiatry trainee, and one day you will be a psychiatrist. I mean, what role do you see for psychiatry in your own practice in the future when it comes to these issues?

So I think it's the same as any other human. People are capable of having mental health problems. And ultimately, if someone's indigenous, we don't go, oh well, they need indigenous medicine. It's similar with trans people. They don't necessarily need psychiatry to handle that part of it. But if someone's depressed, then you know they're still human. They still might need support for depression. They still might need support for eating disorders. The other side is I've just helped OSPAF and PAFA collaborate on something which they've just submitted to the College Journal. But basically, they were asking about well, what can psychiatry offer? And ultimately, one of the things which we could consider is that sex hormones are actually neuromodulators. They're things which improve mood, change mood. And actually, we had a talk on a very similar field in women only yesterday at the Congress about actually you can consider progesterone and estrogen as a treatment. It's no different in that sense. And actually, it might help mutually build those things because in trans women you've got people that don't have cyclical hormone variation. They're your perfect control group for trying hormonal interventions to see whether they work in theory.

So you're sort of seeing it as treatment of syndromes, whatever they may be, as they emerge in an individual, as opposed to just being attached to the fact that someone is coming out as trans or non-binary or whatever it might be.

I think it's a combination of the two. Because actually, you know, there's there's good evidence about what's called minority stress theory. If anyone's interested in that, I recommend looking into the work of uh Jamie Veal from the Trans Research Lab at the University of Waikato. Again in New Zealand, Aussies catch up. But basically what it's what it suggests is that it's not depression in the traditional sense, but it's actually a product of the societal stigma and the pressure which one experiences from being trans or from attempting to assert a non-binary gender expression in the world which is quite hostile towards it. And you get depression, you get anxiety, you get eating disorders as a as a product of this. And what the evidence is starting to overwhelmingly show is that actually if you help people to affirm their gender, in particular kids, then actually these conditions go back to baseline.

Before we recording here at the Congress, um you've already given a uh a presentation earlier in the week, and I was wondering if you might be able to maybe give a bit of a summary or talk a bit about some of the main themes that you came through with that presentation for those who couldn't be.

Effectively, what we we talk about is this idea of cultural safety and humility, and how this doesn't merely apply to indigenous groups and ethnic minorities, although I'd I'd be doing them a disservice to say that it's not building upon the work of those voices. But it's to say that actually this applies for other marginalized groups, inclusive of the trans community. And it's about how we build that in a way which we can move forwards hand in hand and in a collaborative fashion. But come as some of the main issues are kind of this recognition of, you know, ultimately the trans community doesn't trust psychiatry. They've had good reason not to because of mistreatment. You know, we talk about legacies of abuse from governments in terms of indigenous people. But to trans people, the abuser has been the psychiatric profession. And yet we've ended up in this marriage of convenience. I was reading a book recently where gender medicine gets described as a platypus. It doesn't quite fit in with the ducks, it doesn't quite fit in with the mammals. And it's it's a good metaphor for it, but ultimately we've ended up under this banner of psychiatry at a time when perhaps that's not the best place for it, and we need to let go. And I don't think that there's really been a historical precedent to a similar degree. You know, you can look at homosexuality as a parallel, where we, as a specialist group, have been asked to let go of a diagnosis and give it to someone else. And I think that's part of the pushback we're feeling at this point, is we don't like things being taken off us.

Yeah, it gets a bit territorial. I think in your letter to Australasian, also at the ANZJP, you were suggesting that the GPs be better placed than psychiatrists to sort of manage the health issues around this kind of thing. Is that what you're suggesting?

Or yeah, so in terms of the the broader service delivery models, there's there's various different ways in which this has been handled, and the Canadians and I'm gonna toot our own horn here, the Kiwis are world leading in this respect. And if I know anything about this college, it's that the way you mobilize the Australians is you tell them the Kiwis are doing something better. And they are, absolutely. But it's it's what they've done is they've moved it towards a spoken hub model around centered around GPs where people can approach the GP and say, Well, actually, I feel like I need help with this aspect of it, I want this aspect of transition. And it's putting capacity back into the hands of the patient. Ultimately, it's if it's no longer a psychiatric disorder, we're not justified in doing psychiatric assessments by default. So the role of psychiatry should no longer be around capacity assessments by default. We should no longer be effectively requiring people to have long-term therapy with no clear endpoint, just because. Because ultimately the end point becomes, oh, this person's decided that they've got a cisgender and non-transgender identity at this point. But ultimately, that means that if they continue to express a trans identity, then you just carry on the therapy for forever. So it's a conversion practice by another name. Someone called Florence Ashley, who's a bioethicist from Canada, really leading work in this area, has just published a book, but probably explains this way better than I possibly could.

I might just add uh yesterday, so May 17th was Ida Hobbit. And the origin of that, of the celebration of that day is um, in fact, the day on which in 1990 homosexuality was removed from the DSM as a mental illness. And that was sort of the the beginnings of people sort of taking this day to celebrate and to recognize the struggles of um the LGBT, QIA plus community throughout history. And that occurred sort of on the back of a more generalized sort of reclassification in the in the DSM, as well as uh many sort of countercultural and gay liberation activist projects in the US in the late 1960s and early 1970s. And when we're talking about visibility at sort of psychiatric congresses, I'm reminded of an image that I saw from a 1972 panel on homosexuality at the American Psychiatric Association uh conference, in which a closeted gay psychiatrist who's since come out as Dr. John Fryer presented on the panel wearing a mask and using a specific through sort of a voice distortion technology on his microphone in order to have his voice heard without revealing himself. And I think that you know the fact that so many of the LGBTQIA plus community are able to live more openly and more freely today is very much indebted to the fact that you know psychiatrists around the globe came together and decided to remove that as a um from its classification as a mental illness. And I think that it's really important for us to acknowledge the way that visibility has really become much more possible as a result of that change.

Yeah, you sort of get the sense of um history repeating itself. I mean, you had this experience in the US with homosexuality, and now we're seeing Zoe on the back of your advocacy and your speaking here at Congress this year, you said that you've already been in contact with multiple trainees and fellows within the college that are gender diverse and didn't even know that there were other people in that same position as them within the college, is that right?

Yeah, so one of the things that we've been able to do off the back of, you know, one person standing up and being visible, because just proving that it's possible to exist in a space is often enough to give people confidence to do the same. And there's a chance they'll be hit with a backlash, I hope it isn't. But by showing visibility, you enable more visibility in the workplace, which actually, you know, in the context of all the trans kids that we're seeing now coming through, particularly, who are really struggling. If we can't sort out our own house, how can we hope to help these kids as well? So one of the things we did manage to do was start getting together a gender diverse support group informally. I happen to have been in contact with some people through other channels before. And I think we've managed in 24 hours to rustle together about 10 of us. And one of the things I'd say from this podcast is if there are gender diverse trainees listening from other places around our two nations, please do get in touch either with, I'm sure these guys will be happy to forward you on to me. And I'm I'm more than happy to incorporate you into the group because I think this mutual sense of support and this sense that you're not alone is essential. It's essential in making people feel comfortable, it's essential in getting a shift in our culture as a college. But it's also essential in meaning that we can educate and move forwards in a way that means that we stop failing trans kids, we stop failing trans people who are seeking our help as psychiatrists. You know, off the top of my head, I can tell you that the data says that one in nine trans people will have attempted suicide in the last 12 months. From personal experience, I can no longer remember how many friends I've lost along the way. And it's tragic, and the same's true of every trans person you meet. They know people that have killed themselves while on waiting lists or, you know, in other circumstances.

Just on visibility, I suppose, here at this conference, what has the reception been like to the talk that you gave of people come up to you afterwards and giving either positive or otherwise feedback about what you talked about?

Yeah, I've had a couple of people come up. I think the nicest thing for me was, you know, the likes of FIO were kind of coming up and introducing themselves and sharing their experience as well. We had another fellow who spoke up at the back about their kid who's trans and about, you know, thanking the fact that we're we're attempting to shift this and change this. I I got my token, oh, you're so brave, from I always think it's not activism unless a well-meaning older white woman comes up to me and tells me I'm brave afterwards. But ultimately, when people tell you that you're brave, it's less about the fact that you're brave. It's more about the fact that they recognise that the culture's toxic and they recognise that you're in danger, which is always a really interesting thing to be called. But there's been a couple of conversations since, and hopefully they'll they'll progress things. I'm really mindful of the fact that we've we've kept Theo in silence for a little while. Theo, what did did you have anything to add?

I mean, I I guess it's sort of in in relation to your talk, Zoe, one of the things that you mentioned in that was that in the last 52,000 minutes of RANZCP Congress talks, that there had been a mere 90 minutes that were uh dedicated to trans and gender diverse healthcare.

In terms of what we've done as a college, you know, what I was speaking about, I did a review of the titles based on the Congress grids from the last, as many as I could get, and the college had back to Adelaide in 2017. And Adelaide was the last time we had anything on trans issues. This is a six-year gap. And it is, you're entirely right, 52,000 minutes of material and 90 minutes, and that was including my talk, was on trans trans issues. But in the meantime, we're happy to present ourselves as experts and put out a position statement, and ultimately we're not really discussing this openly. The position statement didn't have any input from trans voices, anyone with lived experience, which, if you look at the context of other position statements we released last year, we looked at um uh lived experience of mental illness, we looked at supporting carers of mental illness, we looked at Maori and Indigenous experience. All of those had the value of lived experience. So my question to the college is why are trans people any different? Why don't we deserve a voice in terms of telling you in terms of our own health care? And why is the college happy to put itself in this position as being an expert when ultimately we're not talking about this, we're not having discussion, and then things are being decided behind closed doors in a way that doesn't actually allow those with lived experience to contribute. And this is something that, again, I'd I'd really encourage people to go and have a look at this talk if they're interested. Because ultimately, I promise you, if you'd have had lived experience, we'd have ended up with a very different statement. Because people are aware of the history, they're aware of the harms that have been done along the way, and with that context, which is an important part of humility and safety, you end up with a very different view.

I'm just trying to think of like some sort of like take-home, I mean, take-home messages is a bit cliche, but things that we can get out of today's discussion that maybe people listening can kind of use in a more practical sense. And I think Theo, you touched on the idea of people really trying to self-educate and and get out there and get into some information without necessarily relying on people with lived experience all the time. And I know there's a bit of a paradox there because we are doing that in this instance, and obviously we're learning from you guys, but that seems to be like one theme that I think is coming out of today is that we we should really be kind of going out and learning off our own bat. Is that a fair comment?

I think there's a balance to be struck. And you know, we we reflected it recently in our c in our statement on cultural safety. And one of the things that statement did really well was it reflected the burden that it places on marginalised groups in the context of that statement, it's about indigenous people, where they have a dual role where they almost need to teach people about indigeneity as a way of educating. And it's worth bearing in mind that that has a cognitive burden and it has a value that you'll never reimbursed for. And ultimately, at the moment, we're in a position where I honestly think trans voices need to be doing the education because ultimately that's what we're missing and that's what we need to move forwards. But at the moment, to facilitate that, then what the rest of the college needs to do is they need to take some of the burdens off elsewhere. You need to be doing what you can to challenge prejudice, you need to be creating environments where trans people can thrive and speak up and don't feel unsafe in doing so because by removing that sense of unsafety and that burden and that anxiety that creates, you're freeing up energy in which they can provide that. And it means that we're not starting from zero. You know, at the moment we're at a stage, you know, statistically, 2.7%, one in 40 people are probably trans. There's probably someone in your workplace. And the question I'd give to people is if you don't know someone that's openly trans in your workplace, why is that? And why is it that that person doesn't feel able to come out to you and to share their experience? Because that in itself is a really important question to consider. You know, introspection is the first step in developing humility, developing cultural safety. And if we can answer that question in you know all of the psychiatric workplaces across our two great nations, then actually you'll probably find that people come forward and the opportunities for education come forward.

Well, thank you, Zoe and Theo, for such a stimulating conversation. Um I think there's a lot of points that we can take and um use to move forward in this space. Um it's been really enjoyable, so thanks for coming on the show. Thank you.

You're very welcome. Always happy to come back if you want to talk about other things.

Yeah, thanks so much for having us. It's been been great.

And thanks, Michael. My pleasure. Thank you, David Beal for Joe Rose Fado as well from the RNZCP in their production capacity today, and uh Sidoni Printis for our artwork, Shadi Day for our music, and Australasian psychiatry for giving us this space. Thank you so much.