A flawed model

It is telling that the gender-affirming worldview cannot abide scrutiny and seeks to silence dissent

Photo by Andrew Neel on Unsplash

First, do no harm

“First, do no harm” (primum non nocere) is a fundamental healthcare principle emphasising that a practitioner’s primary obligation is to avoid causing unnecessary injury or harm to a patient. It prioritises safety by requiring that potential treatment benefits outweigh risks, and urges using the most gentle, non-invasive methods first.”

The most important element in this ancient dictum is the right, indeed the obligation, for a health practitioner to question any health practice that raises issues of safety, appropriateness and/or legitimacy.

However, from the early days of the development of the “gender-affirming care” model, advocates have insisted that any young person who states they have gender dysphoria must be supported in that belief, no debate allowed.

As a result, an untold number of health professionals have been silenced, had their professional integrity attacked, and some have lost their employment for asking questions or expressing criticism about gender-affirming care. How can a practice be safe if there is a ban on exploring an aspect of it that is potentially harmful?

One egregious example of the harassment of a concerned health professional is Dr Dianna Kenny, an experienced and well-respected psychologist who has had multiple complaints against her to the Australian Health Practitioner Regulation Agency (AHPRA) for her advocacy of a more cautious approach to gender-questioning minors. Each time she has been required to go through a stressful, lengthy process to support her assessment and management of these clients, and each time it is concluded that she has no case to answer.

Two other health professionals under threat are Dr Jillian Spencer and Dr Andrew Amos, both at risk of losing their authority to practise because of their strongly expressed concerns about the gender-affirming care model. By contrast, gender clinician Dr Michelle Telfer, who was criticised by a Family Court judge in a dispute over puberty blockers for an 11-year-old boy—Devin’s case—continues in employment at her children’s hospital and a complaint against her was swiftly rejected by AHPRA.

No gatekeepers

Gender-affirming health professionals insist that a comprehensive, mandatory mental health assessment of a gender-confused person invalidates self-determination and is a barrier to “essential care”. Instead, they emphasise an “informed consent” model that prioritises immediate access to care, on the grounds that this improves poor mental health.

In Australia, prescribing puberty blockers to a child under 18 generally requires consent from both parents (or legal guardians) and the treating doctor, provided there is no dispute. If there is disagreement between parents and/or doctors about the diagnosis or treatment, a court order is needed.

Gender-affirming clinicians who insist their treatment model is the only appropriate option weaponise the verifiably false claim that the young person will self-harm if not affirmed. This alone should cast doubt on the soundness of the overall practice of the gender-affirming model.

Cause and effect

All health practitioners who see gender-questioning young people agree that these clients typically have significant mental health co-morbidities. These conditions include depression, anxiety disorders, and suicidal ideation/self-harm. High rates of neurodevelopmental disorders (specifically autism spectrum disorder), post-traumatic stress disorder, eating disorders, and substance abuse are also frequently reported.

What is strongly contested is cause and effect. Gender-affirming practitioners insist these disorders are triggered by minority stress, which is the chronic, high-level stress faced by stigmatised minority groups, including LGBTQ+ individuals, racial/ethnic minorities, and people with disabilities, due to prejudice, discrimination, and marginalisation.

By contrast, critics of the gender-affirming model consider that the increasingly high incidence of mental health problems in children and adolescents makes them vulnerable to the influence of social media. On this view, young people are induced to believe that their problems have been caused by previously unrecognised gender dysphoria. The many positive descriptions of being transgender on social media convince them that transition is the solution to their distress.

Gender-affirming clinicians believe that gender-questioning young people must be treated as a special case and have access to their own unique treatment. There is, nevertheless, abundant evidence that gender dysphoria isn’t the only problem that young people are identifying with; there is a much wider problem, as an article from Johns Hopkins Hospital explains—

“Is your child convinced they have obsessive-compulsive disorder, autism, anxiety or depression, perhaps? Increasingly, mental health professionals observe children and teens ‘self-diagnosing’ mental disorders after watching influencers discuss them on TikTok and other social media platforms. While awareness and understanding of mental health issues are important, certain exposure on these platforms can be harmful.”

Other popular diagnoses include ADHD, dissociative identity disorder, Tourette’s syndrome, bipolar disorder and the list goes on. Typically, as is the case with gender dysphoria, these young people are convinced they have the particular disorder. Should the health professional affirm this belief and provide the disorder-related treatment? If not, why not? How are these presentations any different to the minor claiming to have gender dysphoria?

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Advice: US therapist Sasha Ayad on how parents can handle the risks of an “affirmative” clinic

The gay analogy

Some gender-affirming clinicians try to defend the position that gender dysphoria is a special case by comparing it to young people who question their sexuality, the argument being that a health professional wouldn’t tell a young person who claims to be gay that they aren’t gay.

One obvious difference is that supporting the young person’s belief that they are gay does not involve any medical or surgical treatment and therefore the risk of harm is minimal.

One parallel is that the right clinical response to clients questioning their sexuality—or gender—may not be straightforward.

The lesson of my work with sexuality-questioning young people particularly in the 1970s and 80s was that not all minors who presented with the belief that they were gay were in fact gay.

Some boys worried they were gay because they looked at other boys’ penises at the urinal. A boy would catch himself looking, think it was wrong, and then start obsessing about “am I gay?” This would escalate his anxiety, and he would begin “checking” to see if he was gay—that is, he’d tell himself he wouldn’t look, then find himself glancing at the next boy, and panic that it must mean he was gay, setting up an obsessive-compulsive disorder.

Other boys were being bullied, and called gay as an insult. Some felt attracted to boys and hoped they weren’t gay. Even with a boy whose sexuality seemed clearly expressed, we would talk about how to take his time with this, as sexuality can be an unfolding story, so he should not put himself under any pressure but take his time to work out what is right for him. For similar reasons, a young person’s claim to gender dysphoria should not be the end of clinical exploration.

Affirmation is not assessment

Although gender-affirming practitioners like to claim they have conducted an appropriate assessment, I have never seen a sound account of what the assessment covers, nor how the clinician reaches the view that the appropriate diagnosis is gender dysphoria. Instead, these practitioners insist that the first step in working with the young client is to ask their “preferred pronouns”, thus immediately reinforcing the child’s beliefs and shaping the rest of the assessment, such as it is.

The long-accepted assessment process is to conduct a differential diagnosis, which involves considering all options that could account for the individual’s presenting problem, and systematically ruling them out until the diagnosis that best accounts for the person’s situation is identified. This isn’t foolproof, but is recognised as best practice. Such assessment isn’t usually conducted in a rigid, linear way, especially with young people, but aims to discover the origins and meaning of their signs and symptoms.

Given that a declaration of gender dysphoria is frequently accompanied by mental health conditions, other disorders to be considered include body dysmorphia, obsessive-compulsive disorder, social anxiety, depression, anxiety, emerging paraphilia, fantasy role play, gender nonconformity, and confusion about sexuality.

How often are these diagnoses even considered? If considered, by what criteria are they ruled out? What percentage of gender-questioning clients are recommended for gender-affirming care after the first session? After the second? What is the primary diagnosis that is most often arrived at, if gender dysphoria is excluded?

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Identity promotion

Being transgender is promoted on social media as the solution to a young person’s mental health problems and made more attractive by all the special services and support, the days of pride, the flags, all that goes along with it. There is the attraction of becoming part of a welcoming, supportive community, even if only online. Why wouldn’t a vulnerable young person embrace the belief that adopting a trans identity is the solution to their distress?

The evidence is that some people do well after medical and surgical reassignment. Until recent times, only adults had access to what was then called sex-reassignment surgery, and long-term follow-up of these men found that satisfaction rates varied from 68-86 per cent. These results may support medical and surgical transition for some adults but certainly not all, and yet this was a very select group that had to undergo rigorous assessment to be eligible for medical and surgical interventions. What would the poor outcome rate have been with immediate affirmation?

The evidence of the outcomes for the current, younger cohort also suggests that some do well, but accurate information about those who regret medical and/or surgical transition is difficult to accurately determine because follow-up has been poor. Trans advocates claim that because reported detransition rates are low, the gender-affirming care model is validated and should remain the only option for the assessment and management of gender-questioning minors. But there is reason to believe that much detransition goes unreported. In a 2021 survey of 100 detransitioners, only 24 had gone back to tell their clinicians they had detransitioned.

Placebo

The placebo response to any medical or psychological intervention has been extensively investigated and is recognised as a powerful effect in health interventions. Psychiatrist and researcher Dr Alison Clayton describes the gender-affirming treatment of youth gender dysphoria as a perfect-storm environment for the placebo effect—

“[W]e have a population of vulnerable youth presenting with a condition, which has no objective diagnostic tests, and that is currently undergoing an unexplained rapid increase in prevalence and marked change in patient demographics.

“The treatment response is mainly based on patient-reported outcomes … Some clinicians, who may be affiliated with prestigious institutions, enthusiastically promote gender-affirming treatment, including on the media, social media, and alongside celebrity patients.

“Some make overstated claims about the strength of evidence and the certainty of benefits of gender-affirming treatment, including an emphasis on their ‘lifesaving’ qualities, and under-acknowledge the risks. Alternative psychosocial treatment approaches are sometimes denigrated as harmful and unethical conversion practices or as ‘doing nothing’.

“This combination of features increases the likelihood that there will be a complex interplay of heightened placebo and nocebo effects in this area of medicine, with significant implications for research and clinical practice.”

However, the placebo response tends to weaken over time.

The stamp of ideology

The hallmarks of a treatment protocol based on ideology rather than evidence are hostility towards scrutiny, dismissal of any adverse claims, demonisation of those who challenge the dogma, and punishment of anyone who openly challenges the assumptions, beliefs and rules of the preferred protocol.

Good health policy requires that poor outcomes be investigated even if the rate is as low as 1 per cent. There are two aims here: to identify when a protocol is causing harm to most patients, or to identify risk factors for patients who are more likely to have a poor outcome.

Without this most basic requirement for good health care, the public are at risk of ongoing harm: the thalidomide disaster is just one of many examples that took way too long to identify.

Detransition

Regardless of the rate of detransition, these young people should have been identified, supported and investigated from the earliest days of gender-affirming care. Key areas of regret and challenges reported by detransitioners include irreversible medical effects such as mastectomies, genital surgery and permanent changes from hormone therapy. There may be a loss of fertility.

Many detransitioners report that their gender dysphoria did not improve, or turned out to be caused by unaddressed trauma, mental health struggles, or internalised homophobia. They may feel their initial transition was rushed or that medical professionals failed to explore other factors contributing to their distress. They may come to experience uncertainty of identity, a shift in understanding their own gender identity, as they realise that transitioning was not the correct path for them. Often they feel abandoned by the LGBTQ+ community and experience social isolation.

Stages for the development of regret have been identified—

Initial period: Many individuals experience high satisfaction in the first 1–3 years after transition, which may dip around 5 years post-transition.

Long-term factors: Some studies suggest that regret, when it does occur, may not set in until several years after initial procedures, especially as individuals navigate long-term changes.

Early vs late regret: While some regret is reported early, a 2023 study of surgical outcomes suggested a median of 8 years for some instances of regret.

Common drivers: A significant portion of reported detransition is caused by external pressures (lack of support, financial stress, or discrimination) rather than an internal change of heart.

Research is beginning to elaborate the factors affecting the detransition timeline—

Age and procedure: Regret is more common among those who transition earlier or with more invasive, irreversible procedures.

Definition of detransition: Studies vary on whether they measure permanent detransition, temporary detransition, or just an inner sense of regret and uncertainty as yet undeclared to others.

Support structures: The presence of strong social, familial, and professional support correlates with lower, or non-existent, levels of regret.

Restoring reason

The disturbing practice of shutting down and punishing any health professional who dares to criticise the gender-affirming model is unethical and, in my view, more like a toddler throwing a tantrum than a considered response to disagreement.

A recent example involves Finnish psychiatrist Riittakerttu Kaltiala, who is a leading clinician and researcher in the international shift away from routine gender-affirming medicalisation of minors. Last month, she was scheduled to present a webinar—titled “Medical gender-reassignment among minors: why are we cautious in Finland?”—hosted by the Royal Australian College of General Practitioners (RACGP). Her presentation was cancelled after complaints to the RACGP that the webinar would show “hostility to trans people”, imperil “patient safety”, expose the college to a backlash, and damage its reputation.¹

My reaction to this is to wonder whom these complainants are protecting: gender-diverse clients or those health professionals who have nailed their professional future to the mast of a flawed health model and will suffer reputational damage when any flaws in that model are aired?

Hopefully, there is new protection for health professionals desperate to expose the flaws in the gender-affirming model. Recent legal changes in Australia have made it a criminal offence for organisations to retaliate against health whistleblowers, defined as anyone (colleagues, patients, the public) reporting serious misconduct, public safety risks, or corruption.

Practitioners who are critical of trans ideology in general—and gender-affirming care in particular—believe this treatment protocol causes harm to patients and their families. Thus, clinicians such as Dr Spencer and Dr Amos should be protected under these new national law amendments, which would make punishing or silencing them through retaliation or non-disclosure agreements a crime.

Having one model of care that is beyond review and criticism is poor health policy. It is like having anti-vaxxers in charge of immunology or anti-transfusion advocates in charge of the blood bank. Sadly, it may take several legal cases to bring about change. As for the defence that “everybody is doing it”, it won’t wash. The flaws of gender-affirming care should be obvious to any competent health professional. Can we please get the adults back in charge?

Dr Sandra Pertot retired not long ago after 50 years of practice as a clinical psychologist specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity

1. Professor Kaltiala’s webinar went ahead on April 14, hosted by Australia’s National Association of Practising Psychiatrists.