Inquiring minds

We fail our young if we allow gender clinics to be immune from scrutiny

Photo by kevin laminto on Unsplash

Today, Australia’s upper house of parliament, the senate, may get to vote on a proposal for an inquiry into youth gender medicine.

I don’t know if a parliamentary inquiry is the right vehicle. I am confident, however, that popular arguments against an inquiry—against any kind of inquiry—are shot through with holes.

Let’s take them one by one.

We must not politicise medicine. Youth gender medicine is already politicised. The “gender-affirming” medicalised approach is not like any other branch of medicine. It is a hybrid of identity politics and medical technology. When evidence is lacking, politics fills the gap by invoking transgender rights. This is part of a society-wide distortion of institutions and norms by emotive social justice causes. In any case, the role of the medico in the child-led gender-affirming model is limited because the distress of gender dysphoria is in effect self-diagnosed. The sacrosanct trust between health professional and patient is nonetheless invoked to argue that legislatures should not prohibit medicalised gender change for minors, nor even inquire into standards of medical safety. But that same trust is swept aside when politicians are cajoled into passing ill-defined laws against “conversion therapy”, meaning in practice that ethical alternatives to the gender-affirming treatment approach are shut down.

We should not import U.S. culture wars. Too late: the dogmatic gender-affirming way is an American export that already dominates the market in rich countries. Joe Biden’s administration is pushing this “progressive” form of medicalisation not only to unwilling Republican states, but also to diverse, not necessarily receptive cultures around the world, courtesy of U.S. diplomacy. Many Democrats are dismayed by gender ideology, just as there is fierce dissent in centre-left parties and feminist groups across the developed world. It’s European social welfare states such as Sweden, Finland and England which have started the shift away from hormonal and surgical treatments for gender distress to more mainstream mental health strategies.

In these countries, the game-changer has been systematic reviews of the evidence base for medical transition of minors. Using a method that controls for bias and allows checking by others, these reviews have shown the evidence to be very weak. Which means we cannot be confident about the outcomes, good or bad, of puberty blockers and cross-sex hormones. We are embarked upon an uncontrolled experiment.

Trans kids will kill themselves. It’s never put this bluntly, of course, because that would make too obvious the reckless, manipulative nature of this ploy. Instead, we’re told youth gender medicine is very sensitive, involving a very vulnerable population of young people. True, up to a point. But some in the senate predictably recycled the figure that one in two trans kids attempts suicide. That’s from a low-quality, anonymous online survey with an unrepresentative sample and no follow-up to check responses. In the same vein, parents hesitant about puberty blockers or cross-sex hormones are asked, “Do you want a live son or a dead daughter?” Gender dysphoria seems to be a free-for-all where activists can ignore standard mental health warnings about the danger of retailing a simplistic suicide narrative. How does it serve trans-identifying young people to be constantly told by clinicians and journalists that they are uniquely prone to self-harm?

Dr Ken Zucker, a leading international expert on youth gender dysphoria, believes the suicide risk of gender clinic youth is similar to that of young people seen by child and adolescent mental health teams for conditions such as depression. Which makes sense, because patients in gender clinics are often depressed as well as dysphoric. “If you are depressed,” Dr Zucker told me, “your suicidality risk is going to be elevated, but you see that in kids who are depressed but don’t have gender dysphoria. The idea that adolescents with gender dysphoria are at a higher risk of suicide per se is dogma—and I think it’s wrong.” And the gender-affirming model, with its gender fixation, does not seem well suited to the perfectly ethical exploratory therapy that might disentangle the range of mental health and neurodivergent issues affecting many of these young people.

It’s agreed that gender clinic youth need compassionate help. Mental health clinicians are used to working with suicide risk, and this doesn’t require a no-questions rule at the policy level. Quite the opposite. There is an emerging group of young people, known as detransitioners, who regret medicalised gender change—they are certainly vulnerable, often shunned by their former trans community and overlooked by health professionals. They need help. And they may be able to teach lessons about less invasive ways to deal with dysphoria and how to minimise harm to other young patients. We won’t find out unless as a society we can ask sensible questions. Is the gender-affirming approach so fragile that it cannot be scrutinised or debated?

Greg Hunt sorted this. So we were told repeatedly in the senate yesterday. In mid-2019, after my news reports in The Australian quoting clinicians and researchers seeking a national inquiry, federal health minister Greg Hunt asked the Royal Australasian College of Physicians to carry out a review of youth gender medicine. At the outset, the college sent some odd signals, releasing a statement that implied the gender-affirming treatment guideline from the Royal Children’s Hospital Melbourne (RCH) would serve as a benchmark for inquiry, rather than as a document to be critically assessed. I did some digging and discovered that the college had previously lobbied—on one occasion with the RCH gender clinic director—for faster and easier access to the hormonal treatments it was now supposed to examine. No answer when I asked the college about a conflict of interest.

In March 2020, the college served up a four-page letter to Hunt. It followed the “very vulnerable” script, warning of “extremely high rates of depression, self-harm, attempted suicide and suicide”. No data, no citations. No description of the hormonal and surgical treatments favoured by the gender-affirming model, no consideration of any risk attending those interventions, no discussion of less invasive alternatives. The college did, however, see a clear and present danger—a national inquiry “would further harm vulnerable patients and their families through increased media and public attention.” No evidence was offered to support this claim, which reflects an identity politics dogma. Hunt fed the story to The Age in Melbourne, the home town for the RCH gender clinic, which had spearheaded the gender-affirming model in Australia. “In recognition of the risks of further harm to young people, the government does not intend to establish a national inquiry on this matter”—so reported The Age, quoting the health minister’s spokesman. I asked Hunt why an inquiry would do harm, and he sought to disown the claim, suggesting it had been added by officials without his knowledge.

It’s a state responsibility. That’s certainly what Hunt’s office told me back in 2020. The head of the federal health department, Professor Brendan Murphy, was said to be disturbed about the lack of data kept by some gender clinics in state children’s hospitals. Hunt insisted that a state-federal body of senior health officials would deliver what was needed: a new, uniform model of clinical governance across Australia and a common system for proper data collection. As far as I can tell, nothing came of this.

The experts have spoken. There is another review worth revisiting, but I heard no mention of it in the senate yesterday. In mid-2019 a psychiatrist contact and I stumbled across a stealth edit in the LGBT mental health policy of the Royal Australian and New Zealand College of Psychiatry. The March version of that policy had explicitly endorsed the RCH gender-affirming guidelines. In August I began reporting criticism of the rigour and safety of this document, which was badged as “Australian Standards of Care”. The following month, the college’s endorsement of the RCH guideline had disappeared from the policy online, replaced with the bland advice to use “evidence-based treatment guidelines.” There was no announcement about this.

I asked the college what had happened, and they said the change had been made pending a review of the evidence supporting the guideline. Two years later, the college had fleshed out a much more nuanced policy on gender dysphoria. The endorsement of the RCH guideline was not restored (it was tactfully relegated to a footnote). The new policy highlights the “paucity” of quality evidence on the outcomes of gender-affirming hormonal drugs and surgery such as mastectomy. It says “evidence and professional opinion is divided” on whether the affirmative approach should be used with children. It ­reminds psychiatrists of the changes in identity and brain ­development that come with childhood and adolescence, and insists that judgments about the capacity of minors to consent to treatment should be clearly documented. And the policy hints at the risk of lawsuits, warning its members of the “ethical and medico-legal ­dilemmas” posed by these life-­altering medical interventions given within a legal framework that is “rapidly changing”. This review has stood the test of time. So, too, has the cautious guide to managing youth gender dysphoria issued by the National Association of Practising Psychiatrists under its president Dr Philip Morris.

Video: The medical interventions sought via the London-based Tavistock GIDS clinic, the world’s largest youth gender clinic, are the same as those offered at children’s hospital gender clinics in Australia

It’s an attack on the LGBTQ community. In fact, there is growing tension between mainstream LGBs, who cling to biological sex, and the extreme Queer Theory-driven trans agenda, which promotes an inner “gender identity” cut adrift from the body. For these LGBs, same-sex attraction is the real deal. But the TQs want everyone to accept that a male-bodied person who identifies as a woman can be a lesbian—a transbian with a lady penis. Another sharp divide is the medical transition of minors. Mature LGBs recall being young, gender non-conforming and uncertain of their identity. They witness the medicalisation of today’s gender non-conforming youth, and reflect on what they escaped. Some see gender medicine as a form of eugenics, because early puberty blocking followed by cross-sex hormones is a formula for sterile adults and impaired sexual pleasure in the case of males. There are well-known transsexuals who agree with the LGBs that there is an almighty backlash coming when mainstream society understands what it has not been told about youth gender clinics. Who, then, will be under attack?

Update: On June 22, the day this post was written, the senate ran out of time before a vote on an inquiry into gender clinics. The next opportunity is expected in the sittings that start on July 31.