Madness
The illusions of 'gender-affirming care' are a recipe for harm and litigation
Not good medicine
The dominant “gender-affirming” treatment approach—which promotes puberty blockers, cross-sex hormones and mastectomy for minors—is “fundamentally incompatible with competent, ethical medical practice.”
That is the conclusion of a new paper by academic psychiatrist Andrew Amos in the journal Australasian Psychiatry.
Dr Amos says treatment guidelines from the World Professional Association for Transgender Health (WPATH) and the Royal Children’s Hospital Melbourne (RCH) “assert without evidence that pathology plays no part in the development of gender diversity,” which is said to be part of nature.
“If it is admitted there are some pathological causes of gender diversity, then it becomes necessary to assess the health or illness of all presentations [of gender identity],” Dr Amos says.
But the gender-affirming model insists that self-declared gender identity be affirmed, not interrogated for underlying mental illness.
“The emergence of non-binary and fluid genders means there are no boundaries to self-reported gender identity, which may include a gender consistent with one of the two biological sexes; a combination of features consistent with both sexes; the absence of features of gender; an identity as a voluntarily/involuntarily castrated eunuch; or arbitrary and rapidly changing variations,” Dr Amos says.
“From a psychiatric perspective, the proposition that psychopathology plays no role in gender diversity is absurd.
“The most detailed personal description of the experiences of psychosis is that of Daniel Paul Schreber, a German judge who minutely described his belief that God had turned him into a woman and was sending ribbons from the sun through his body to impregnate him and repopulate the earth.
“It is difficult to imagine a more pathological aetiology [or cause] for gender diversity, yet the [gender-affirming model] provides no framework for assessing such a patient, and does not view Schreber’s case as an absolute contraindication to social, medical or surgical transition.
“As Schreber illustrates, it is certain that pathology causes some cases of gender diversity. Differentiating between healthy and pathological gender diversity, or, more likely, gauging the relative contribution of healthy and pathological processes originating within or in the environment of each patient, can only be achieved by the comparison of an individual’s patterns of behaviour with patterns of normal and pathological development.
“While [gender-affirming] advocates have argued transition is safe in patients with psychosis because it is easy to differentiate psychotic from non-psychotic aetiologies of gender diversity, they have provided no guidance on how to do so, and no empirical evidence that it is safe to try.
“To the extent they discuss the role of psychosis or severe personality pathology in the development of gender diversity at all, it is only to deny that either might prevent transition.”
RCH Melbourne’s treatment guideline—promoted as “Australian standards of care”1 and used by children’s hospital gender clinics across the country—states that psychosis in a minor “should not necessarily prevent medical transition.” It does not explain how to discern those cases when psychosis should indeed rule out transition.
In the leaked WPATH Files, clinicians were revealed debating how to manage “trans clients” with dissociative identity disorder (multiple personalities or alters) in which “not all the alters have the same gender identity.”
Dr Amos argues that gender-affirming treatment guidelines “abandon the clinical discipline of diagnosis and make treatment contingent upon the unconstrained subjective experiences of children and potentially disturbed adults.”
“This is unethical, because modern medicine relies upon accurate diagnosis and evidence-based clinical reasoning to ensure that treatment is likely to help and not harm patients.”
Dr Amos notes tension in the 2023 gender dysphoria policy of the Royal Australian and New Zealand College of Psychiatrists between a traditional mental health approach and the unevidenced assertion that, “Being trans or gender diverse does not represent a mental health condition.” This policy area has occasioned sharp divisions within the college since 2019.
“Although it is clear that this [2023 policy] compromise balances the concerns of different stakeholders, the medico-legal implications for psychiatrists and their patients may be too important to long defer a conclusive position on the aetiological role of mental illness in gender diversity,” Dr Amos says.
He points out that the lack of evidence for the gender-affirming model has led an Australian medical defence fund, MDA National, to restrict coverage for private practitioners facing claims because of their involvement in the medical transition of under-18 patients.
Video: England’s NHS has radically restricted puberty blocker drugs, but it’s business as usual for Australia’s gender medicine lobby
“A patient should be more than a number, but detransitioners [who regret gender medicine treatments] can’t even get that. Reclaiming one’s biological gender after a gender transition is so taboo, that there is no way to document it in a medical record with an official diagnosis code.”—FAIR in Medicine fellow Aida Cerundolo, opinion article, The Hill, 15 February 2024
“International Classification of Disease diagnosis codes label patients’ medical issues and electronically shuttle them through the US healthcare system. These letter-number combinations facilitate communication, help prevent medical errors and signal insurance companies to reimburse for treatments.
“Codes exist for patients ‘struck by orca, initial encounter,’ or who have ‘problems in relationship with in-laws’ and even for those ‘sucked into [a] jet engine, sequela.’ However, detransition remains an unrecognized medical entity because it has no corresponding diagnosis code.”
Taking cover
On May 9 last year, GCN reported that MDA National planned to restrict cover for private doctors assessing minors as eligible for medicalised gender change or initiating cross-sex hormones for them.
The insurer cited “the high risk of claims arising from irreversible treatments provided to those who medically and surgically transition as children and adolescents.”
The news appears to have alarmed the lobby group LGBTIQ Health Australia (LHA)2, whose access to federal Health Minister Mark Butler produced an “URGENT one day turnaround” brief from his department on the issue, according to documents obtained under Freedom of Information law.
These documents suggest Australia’s federal government is focused not on the international debate about safety concerns and the lack of evidence for youth gender medicine, but on expanding access to gender-affirming treatment as requested by well-connected LGBTQ lobbies.
On May 23, LHA chief executive Nicky Bath—who sits on the government’s LGBTIQA+ Health and Wellbeing 10 Year National Action Plan Expert Advisory Group—alerted Mr Butler’s office to MDA’s proposed restriction of insurance cover. (By market share, MDA is the second largest medical defence fund.)
That same day, the Department of Health and Aged Care3 secured a detailed account from MDA chief executive Ian Anderson of the insurer’s rationale for the change to take effect from 1 July 2023.
In its urgent brief sent to Minister Butler on May 30, the department relayed Mr Anderson’s explanation that—
While MDA itself had not received any claims arising from gender medicine, the insurer was aware of claims emerging with other indemnifiers in Australia and overseas
Members of MDA had expressed concerns about growing demand pressuring general practitioners (GPs or primary care doctors) to prescribe cross-sex hormones for minors
Those concerns included whether the usual consent would be sufficient for children, given the life-changing, permanent effects of such treatment; and reliance on medical opinion influencing that treatment decision in the event of a claim brought by a former patient
For these reasons, MDA had investigated the underwriting risk of claims arising from gender treatment of minors and concluded that it was unable to quantify and price the risk, quantum and frequency of claims; nor was it able to source appropriate data
MDA members with experience in gender medicine had stated their view that the best model for assessment and treatment of gender-distressed children involved a multi-disciplinary team backed by “a significant hospital”
In its brief, the minister’s department makes no reference to systematic reviews overseas showing the evidence base for paediatric transition to be very weak and uncertain.
However, the note suggests that if the regulatory Medical Board of Australia had to intervene in a case involving gender treatment of a minor, it would use the treatment guideline issued in 2018 by the gender-affirming clinic at the Royal Children’s Hospital Melbourne (RCH) and badged as “Australian standards of care.”
“In determining what is safe clinical care and what is the best available evidence, doctors should have regard to relevant Australian standards of care,” the briefing note says.
There is no hint of the controversial status of the RCH treatment guideline.
The department’s note says the RCH guideline “clearly outlines the role of GPs in the assessment and care of adolescents with gender dysphoria”, which the note says includes prescription of puberty blockers or cross-sex hormones “in collaboration with a paediatrician, adolescent physician or paediatric endocrinologist.”
However, towards the end of 2023, the RCH gender clinic changed precisely this section of the guideline consistent with a campaign by the gender-affirming lobby to ramp up GP provision of cross-sex hormone treatment for minors—the very issue that MDA was concerned about.
Gender-affirming clinicians see the mainstreaming of hormones through local medical practices as one answer to long waiting lists at children’s hospital specialist gender clinics, where older adolescents may age out before treatment.
The current, version 1.4 of the RCH guideline still says a multidisciplinary approach is “the optimal model of care” but adds new advice that, “GPs with sufficient expertise and skill in initiating and monitoring [cross-sex] hormone therapy can consider initiating and optimising hormone therapy for [minors].”
“This would typically be within a primary care-led multidisciplinary team tailored to the patient’s needs and availability of services…” (Emphasis added.)
It is not explained how GPs will know when they can go ahead without a multi-disciplinary team. Version 1.3—still available on the RCH website—did not recommend that GPs initiate cross-sex hormones without the precaution of specialist back up.
In November 2023, gender-affirming GPs keen to mainstream hormones for 16- and 17-year-olds without specialist back up complained of mixed messages as to whether or not they would be covered for this4 by the country’s largest medical defence fund, Avant.
Avant, which is understood to be defending psychiatrist Dr Patrick Toohey against a 2022 claim by detransitioner Jay Langadinos, told GCN it had not changed its cover. The fund did not answer the question whether it would cover claims arising from GP members initiating opposite-sex hormones for 16- or 17-year-old patients without the backing of a multi-disciplinary team.
Version 1.4 of the RCH guideline did not cite any new evidence supporting the practice of GP-led hormones, nor was the opportunity taken to cite fresh data reported since the guideline was first issued in 2018.
The RCH document makes no reference to systematic evidence reviews in Finland, Sweden and England since 2019. These reviews, undertaken independently, found the evidence base for hormonal treatment of minors to be very weak and uncertain.
All four authors of the document promoted as “Australian standards of care” are from the one gender clinic at the Royal Children’s Hospital Melbourne. None of the authors is a specialist in endocrinology, although hormone treatment is central to the guideline.
In 2015, LHA successfully lobbied for removal of the rule that only males could be prescribed taxpayer-subsidised testosterone intended for androgen deficient patients; this opened up synthetic testosterone to trans-identified females seeking to masculinise their bodies.
In 2022, Australia’s federal health department was judged a winner in the Australian Workplace Equality Index (AWEI), which is an enterprise of ACON, a former gay rights lobby now promoting radical trans rights. In 2021, the UK Department of Health withdrew from the diversity champions scheme of Stonewall—the model for AWEI. Critics of these schemes say they involve institutions paying fees to implement the gender ideology of LGBTQ lobbies, thereby creating conflicts of interest.
Emeritus professor of law Patrick Parkinson has stated his opinion that it is not lawful for GPs to prescribe cross-sex hormones to minors without the involvement of an expert multi-disciplinary team such as are found in a children’s hospital gender clinic. In 2021, following an article co-authored by Professor Parkinson, the TransHub website of ACON—now funded by the NSW state government to deliver gender-affirming care—took down its claim that, “Any GP is able to prescribe gender-affirming hormonal therapy for most people aged 16 and above, without requiring approval from a mental health professional or endocrinologist.”
Given the right case & a clear-eyed judge, the guideline will be eviscerated.
I think it’s significant that the promised major revision to the guideline was to be led by RCH but following Telfer ceasing to be director of the gender clinic we were told that AusPATH would take charge of the revision, if there ever is one.
How the Australian Standards of Care were ever accepted as a reliable guideline is beyond me. The NHMRC refused to endorse them because none of the studies that they were based on were robust enough. And yet they were published and all Australian gender clinics follow them and refuse to change course despite multiple international jurisdictions either banning or severely restricting treatment advocated by the guidelines.
When, if ever, is Australia going to realise that this is a massive scandal which will only get worse the longer the clinics and or the government sit on their hands and do nothing to stop it.