Misplaced Pride

Celebration of "diversity" in children's hospitals looks like a mask for covert promotion of the contentious gender-affirming treatment model

Photo by John Schaidler on Unsplash

Below is a lightly edited version of an opinion article rejected by the journal Australasian Psychiatry.

One anonymous reviewer objected to the focus on gays and lesbians, referring to them as “cisgender monosexuals who identify as gay or lesbian”, and making the queer-theory claim that “trans people can also identify as gay or lesbian”. This reviewer also characterised gay and lesbian as “predominantly Western identities” transcended by “LGBTQIA+ people”.

The reviewer contested the article’s focus on gays in the 1969 Stonewall Riots because this implied that police mistreatment was “only experienced by gay men”. It has become a woke article of faith that Stonewall records not the start of the modern gay rights struggle but trans leadership of the LGBTQetc movement.

Fred Sargeant, who was present at the Stonewall Riots and involved in the first ever Pride event in New York the following year, has debunked this fake history. Trans radicalism and queer theory, in fact, were piggybacked onto the gay and lesbian rights movement decades after Stonewall. The recent emergence of a new generation of LGB organisations testifies to the inherent conflict between same-sex orientation and the new concept of “gender identity”.—Bernard Lane

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Jillian Spencer, Roberto D’Angelo

The first Pride Parade took place in June 1970 in New York, a year after the Stonewall Riots. These riots were in response to exclusionary, humiliating and brutal treatment of gay people attending licensed venues. Three years before the riots, in 1966, gay New Yorkers had won the right to drink in bars. However, this right was contingent on hiding any trace of homosexuality: kissing, dancing or seeking to “hook up” was considered disorderly conduct. Gay bars were repeatedly shut down by police.

The Stonewall riots triggered the gay-rights movement across America and worldwide. Campaigners initially sought the establishment of gay-friendly public places where they could meet without fear of arrest. The movement successfully achieved this, as well as the legalisation of same-sex sexual activity, the right to serve openly in the military, the legalisation of same-sex marriage and protection from discrimination in all areas of public life.

The rainbow flag was designed by artist and activist Gilbert Baker in 1978 at the request of Harvey Milk, an openly gay politician in San Francisco. It was intended to be a unifying symbol representing the fight for equal rights and freedom from persecution by gay and lesbian adults. It was not intended to appeal to children.

IDAHOBIT (International Day Against Homophobia, Biphobia and Transphobia) was started by US gay rights organisations in 2005 to commemorate the 1990 decision by the World Health Organisation to remove homosexuality from its list of mental disorders. The day was originally called the International Day Against Homophobia. Transphobia was added in 2009, and Biphobia in 2015.

Wear it Purple Day was founded in 2010 as an “annual expression of support and acceptance to rainbow young people” by a group of young Australians concerned about a higher risk of suicide in young people struggling with issues of sexuality and gender.

Into the hospitals

As paediatric gender clinics were established in public tertiary children’s hospitals around Australia from the 2010s, gender clinic staff became instrumental in changing hospital culture more broadly. One such impact was the hosting of LGBTIQA+ celebratory events for Pride Month, IDAHOBIT and Wear It Purple Day. Similar events are held in children’s hospitals around Australia. LGBTIQA+ events in children’s hospitals are usually held within high-traffic public areas of hospitals, traversed by patients and their siblings. Children’s hospitals in Australia generally provide health services for children aged 0 to 16.

One example of a children’s hospital’s Wear It Purple Day celebration is available online, titled “Optimising health—systematic change”. As shown in the video, the events involve staff wearing colours deemed significant to LGBTIAQ+ people (rainbow colours or purple); ally, pronoun and trans-pride badges; and other visual symbols of LGBTIQA+ acceptance, such as ribbons, face paint and headgear. Events may include colourful foods, such as rainbow cakes, and fun activities like dancing, artwork and games such as egg and spoon races. At the events, staff seek to “raise awareness” of the higher risk of suicide and self-harm amongst LGBTIQA+ people and to convey to children and adolescents that diversity is something to be embraced.

The rationale for the events appears to be twofold. Firstly, to assist children with emerging “diverse sexualities or genders” to view themselves positively and to allow them to connect to other children or adults also with diverse sexualities or genders. Secondly, the events exercise social influence more broadly upon children and adults, including hospital staff and parents, to increase acceptance of diverse genders and sexualities—and of the belief that the diverse genders of children should be affirmed and celebrated. This is the systematic change that is sought.

LGBTIQA+ celebratory events are part of the “gender-affirming” model of care (GAMOC) that underpins all paediatric gender clinics in Australia. The GAMOC assumes that children with gender distress are naturally trans or gender diverse. The GAMOC is, in turn, based on Minority Stress Theory, which theorises that mental health problems in “trans or gender-diverse” children result from experiences of social discrimination or abuse and should be addressed through affirmation, connection to the “queer” community and advocacy for “trans” rights. Minority Stress Theory was proposed in 1995 to account for higher rates of mental illness in adult gay men. There is no empirical evidence that the theory is applicable to children with gender distress.

A marketing strategy

That LGBTIQA+ events were not held in children’s hospitals prior to the establishment of gender clinics suggests their purpose relates primarily to gender more than to sexuality. This may explain why the events incorporate activities more suitable for prepubescent rather than adolescent children. The full GAMOC involves socially transitioning prepubescent children and the prescription of puberty blockers from the start of puberty to prevent secondary-sex characteristics from developing.

While increasing societal acceptance of diverse sexualities and genders is laudable, we argue that this is not the aim of these events. The branding of the events as LGBTIQA+ is misleading. It provides a cover of legitimacy, framing the event as grounded in support for diversity, social justice and human rights. This is a marketing strategy which appeals to hospital administrators and wins over parents and adolescents, distracting them from the more covert aim of promoting the GAMOC. This appropriation and misuse of symbols of gay and lesbian rights to make gender concepts “fun” for children trivialises the historical struggle for gay liberation and is therefore arguably homophobic.

Gaining the trust and engagement of children using fun activities is disingenuous and concerning because the issues at play—sexuality and gender identity—are serious and, in the case of gender identity, also entail serious risks as discussed below. We believe the events minimise the complexity and implications of diverse genders and sexualities. Most concerningly, they present transitioning in a frivolous light. This is an unethical misrepresentation that is designed to promote the GAMOC and avoid any focus on risks and harms.

Gender non-conformity is very common in children who will grow up to be gay or lesbian adults—so-called “proto-gay” children. Presenting gender identity and transitioning to children who are experiencing gender non-conformity could promote the idea that this non-conformity necessarily equates to a transgender identity. This may reinforce restrictive gender stereotypes—for example, if you are a feminine boy, you are probably really a girl. In this sense, the GAMOC entails covert homophobia that is actually hostile to gender non-conformity.

Surveys of detransitioners have found that many realised after transitioning that they were actually gay or lesbian and would not have transitioned. It is important to consider that homophobia is still prevalent in our culture and clinicians working with vulnerable youth must reflect carefully on how even the most well-intentioned actions may communicate implicit homophobia.

Fun that may harm

Conveying that diverse sexualities and genders are to be celebrated presumably requires an explanation of sexuality and gender concepts to children attending the events. Given the hospital setting, children attending will have various developmental, physical and mental health conditions. Promoting the affirmation and celebration of “diverse genders” may cause harm to some children by encouraging them to view their own social, developmental or emotional difficulties—or their discomfort with their developing body or the prospect of adulthood—through the lens of “trans”. Being transgender may provide both an explanation and a fantasied solution to relieve them of the issues they struggle with.

The aetiology of trans identification and gender dysphoria is an area of intense debate. While some argue that gender is innate and has no cause, others argue that trans identification can be a manifestation of, or carrier for, a range of developmental and psychological difficulties. Ideally, an exploration of gender identity should occur in the context of a professional relationship in which a developmentally informed clinician can consider the child’s overall situation and provide accurate information about the risks and benefits. This may not be possible with the gender clinicians who run the children’s hospital LGBTIQA+ events as they are mandated by their employers to provide care according to the GAMOC, which precludes a long-term exploratory approach.

Many children who identify as trans will at some point seek hormonal and subsequently surgical interventions, according to the GAMOC. For those young people who do have gender dysphoria, it is important to note that the evidence that interventions provide mental health benefits to children and adolescents is weak and uncertain. Furthermore, these interventions are associated with a range of known harms, including: infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications and regret.

Hospitals do not appear to seek verbal or signed consent from a child’s parent/guardian for conducting this gender and sexuality education through LGBTIQA+ events. That education about gender and sexuality is the responsibility of a child’s parents/guardian is enshrined in Australian law. Section 61B of the Family Law Act 1975 sets out the basis of parental responsibility to make decisions about a child’s education, religious and cultural upbringing, and child health.

Hospitals for all

Public hospitals are tasked with providing healthcare to all children, including those who belong to cultural and religious groups that do not subscribe to a belief that children may be born in the wrong body. Some parents may not be comfortable with outsiders presenting material on sexuality to their children and a significant segment of the community is not supportive of paediatric gender medicine. It is important that public hospitals do not marginalise sections of the community they serve, lest they deter help-seeking.

Ethical questions regarding consent are relevant even to adolescent inpatients who may seemingly have “Gillick capacity” to consent to attending LGBTIQA+ events in the hospital. Hospitalised adolescents who are ill, lonely and dislocated from familiar environments may be more vulnerable to perceived pressure to enact the wishes of hospital staff on whom they depend for their basic needs. The “fun”, “frivolity” and social connections offered during hospital LGBTIQA+ events may be a relief from loneliness. An adolescent’s adoption of LGBTIQA+ political beliefs taught in hospital may set them at odds with their family if the beliefs do not accord with values their parents are trying to instill.

Homophobia remains common in Australian high schools. In seeking to convey acceptance and inclusion, LGBTIQA+ events in children’s hospitals may create a false impression that a young person is likely to be similarly celebrated in their own social environment after revealing their same-sex attraction to others. “Coming out” as gay or lesbian to family and friends has traditionally occurred in late teenager years or in early adulthood, once the young person has a settled sense of themselves and has engaged in intimate relationships. In this way, LGBTIQA+ events in children’s hospitals may be encouraging a premature disclosure of sexuality which could result in a degree of psychological harm.

Hospital administrators may not be aware that “diverse sexualities” and the “+” in LGBTIQA+ incorporates fetishes such as BDSM, nullification (eunuchs), and sexualised role play such as “puppy play” and “age play”, which involve adults dressing as dogs or children for fetishistic purposes. Whilst the hospital events do not include representations of these sexual fetishes, they may inadvertently place children at risk of premature exposure to adult concepts by promoting broad-based acceptance of all LGBTIQA+ sexual diversity without discernment. Children may feel emboldened to explore LGBTIQA+ information online. Parents may mistakenly assume that their child’s safety is not at risk at a hospital LGBTIQA+ event.

Hospitals may incorporate children from mental health inpatient units in LGBTIQA+ events, such as by asking these children to create artwork for display during the events. Children hospitalised with mental illness may be particularly vulnerable to seeing “trans” as an explanation for their complex difficulties. The GAMOC provides a series of defined treatment steps towards “gender euphoria” whereas most mental illnesses usually do not have a similarly defined pathway towards recovery with unsubstantiated claims of highly positive outcomes.

Finally, there is some evidence that staff regard hospital LGBTIQA+ events as an opportunity to discuss with child and parent attendees an elevated risk of suicide among LGBTIQA+ people. The GAMOC for children with gender dysphoria has not been shown to reduce suicide risk. Most concerningly, it is well established that public discussion of suicide can lead to increased risks of self-harm and suicide unless very thoughtfully presented.

Dr Spencer is a child and adolescent psychiatrist. Dr D’Angelo is a psychiatrist and psychoanalyst.

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