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New therapist group on the watch
The "affirmation-only" mindset is coming under challenge from health professionals
A new Australian group has been launched for health professionals in favour of ethical, open-minded alternatives to the dogmatic “affirmation-only” treatment approach with young people who question their gender.
Founded by registered nurse and psychotherapist Jenny Kyng, the Active Watchful Waiting group hopes to bring together health and allied health professionals concerned about the weak evidence for the gender-affirming approach and its potential to do harm.
“I think we need to unite health professionals who are concerned about these developments,” she told GCN. “A lot of people are very afraid to speak out, but I know a lot of people are very concerned.”
She said the group had launched earlier this month with a Facebook page and about a dozen foundation members. It plans to build up a database of articles and information about gender-affirming ideology.
In its more radical form, the gender-affirming worldview holds that even very young children can be experts in their opposite-sex “gender identity”. Advocates for this approach talk up the “autonomy” of legal minors to consent to medicalised gender change, playing down the cognitive immaturity of children and adolescents.
Ms Kyng, from the state of Tasmania, said the Active Watchful Waiting group would mobilise practitioners to seek a parliamentary inquiry into under-18 gender medicine.
Consistent with the international trend, Australian children’s hospital gender clinics are experiencing a dramatic increase in patients, chiefly female teenagers, identifying as transgender or non-binary.
Gender-affirming clinicians claim that puberty blocker drugs and synthetic cross-sex hormones can bring mental health benefits for young people diagnosed with the distressful condition of gender dysphoria.
Ms Kyng said she believed that social contagion was at work, with young people drawing gender dysphoria features from the “symptom pool” and using this diagnosis to define and express their very real distress, which in truth might have other unexamined causes.
“I’ve worked with young people in an eating disorders ward, in a drug and alcohol ward,” she said. “I just know how vulnerable they are and how susceptible they are to influence.
“So the kids I looked after would now be gravitating — quite possibly, subconsciously — towards gender dysphoria, as a way to express their distress, especially with all the gender ideology in schools and social media, with all the gender ideology emanating from health professionals and therapists.
“It's very hard for kids to escape this way of defining their distress.
“And I see it as a scandal that we're basically experimenting on vulnerable young people with [trans medical] treatments that are irreversible and potentially damaging.”
Ms Kyng said she had always taken an interest in medical and psychiatric interventions that lacked good evidence, such as the lobotomy procedure, which won the 1949 Nobel prize in medicine for its pioneer, Egas Moniz; and the 1980s-1990s “satanic panic” and “repressed memory scandal”, which did great injustice with false accusations of child abuse.
She said Active Watchful Waiting hoped to educate the public about the weak evidence for gender-affirming medicine and growing concerns about the risks for young people.
“I don't think the public has any idea what's going on,” she said, citing the failure of most mainstream media outlets to report the story properly.
Ms Kyng said the new group would offer “solidarity” to health professionals who might come under pressure if they spoke out about their belief that the gender-affirming approach is incompatible with their ethical and clinical duties.
Gender-affirming activists have lobbied health professional bodies and regulators to capture policy positions and shape ethics guidelines, as well as turning complaint procedures against clinicians who question gender-affirming dogma.
Champions of the novel concept of a “gender identity” cut loose from biology have repurposed the 20th century bogeyman of “gay conversion therapy” to suppress ethical treatment alternatives in the youth gender space, thereby entrenching the gender-affirming medicalised approach as the only lawful possibility.
“That's a real inhibition of psychotherapists’ autonomy and decision-making,” Ms Kyng said. “It’s not therapy, if they’re just ‘affirming’ someone. They didn't train for three years to just affirm people in something they believe.”
Tasmania is the latest Australian jurisdiction to consider a new-look ban on conversion therapy. What used to be “gay conversion therapy” has supposedly morphed into attempts to change not just someone’s sexual orientation but also their “gender identity”. Hence, the SOGI acronym that turns up in one country after another as gender identity activists try to piggyback on gay liberation.
A new report from the Tasmania Law Reform Institute sprinkles the term SOGI liberally across its 316 pages. That shows conflation of the nebulous idea of gender identity and the known quantity of sexual orientation.
Sure enough, the institute intones that gender identity, like homosexuality, must be “similarly legally depathologised”, but adds a caveat: “[Law] reform must not undermine, or have a chilling effect on supportive, evidence-based medical practice designed to support or treat mental health symptoms relating to gender dysphoria/incongruence”.
So, in truth, the term SOGI joins two different things. When psychiatry’s diagnostic manual, the DSM, finally removed homosexuality as a disorder in 1987, that depathologising was consistent with an end to unethical medicalised interventions supposed to effect a “cure”. Depathologising an opposite-sex identity, however, has involved tweaking terminology in the DSM — from gender identity disorder to gender dysphoria — while seeking to keep a diagnostic (and insurance) justification for medical interventions to “affirm” that identity.
The British government says it will split SOGI, so that only gay conversion therapy will be banned. The concern is that legislative protection for something as ill-defined as gender identity might well complicate ethical treatment of gender dysphoric youth, and lead clinicians to abandon the field as too risky. The minds of ministers were no doubt concentrated by worrying material from Dr Hilary Cass’s review of gender dysphoria care for minors.Good to speak to + on how proposed conversion therapy legislation risked inadvertently morphing into a intervention into a clinical discussion on how best to support young people with gender dysphoria, currently subject of Cass Review (typo = medicalised)“If you come out as trans, you may end up going down a highly militarised pathway with lifelong consequences. That's why you want to be really careful in this space.” Nikki da Costa, former head of legislative affairs at Number 10, talks about conversion therapy on #TimesRadio https://t.co/PpxeOtqbFaTimes Radio @TimesRadio
As for the Tasmanian proposal, it may have something to displease everyone. The advice is to entrust “gender-related disorders” to the state’s chief civil psychiatrist under the Mental Health Act. This might look “pathological”, and psychiatrists have often been accused of “gatekeeping” by trans rights activists who seem to regard hormonal and surgical treatment on demand as a human right.
Only certain classes of health practitioner would be allowed by Tasmanian law to treat gender dysphoria, and they would have to follow clinical guidelines developed by the chief psychiatrist. So, the nature of those guidelines would be important, and Tasmania’s law reformers manage to both prejudge this guidance and leave it open to change.
They accept that the contentious treatment guidelines from the Royal Children’s Hospital in Melbourne are “the appropriate standard of care” for gender dysphoria, and that Australia’s current standard of care is “gender-affirming”. They suggest that the chief psychiatrist’s clinical guidelines should “be based on, reference or incorporate” the RCH treatment guideline. At first blush, this looks like an enthusiastic endorsement of the gender-affirming treatment approach — an approach that is coming under increasing international scrutiny for its weak evidence base and risks.
But the law reformers have more to say. They concede that “the scientific and clinical understanding of and approach to gender identity questions and disorders like gender dysphoria/incongruence is not settled and continues to develop”. That contradicts the story of the 2018 RCH treatment guideline as representing a consensus that the science had spoken loud and clear, and that its language was gender-affirming. It is also in stark contrast to the hasty conversion therapy bans in Victoria and the ACT, which fail to give weight to the unintended consequences for young people who present to clinics with what appears to be, at least on the surface, gender issues. Queensland’s bill was amended to give more leeway to the professional judgment of practitioners.
The Tasmanian proposal is that the chief psychiatrist would be empowered to “revise and update” the clinical guidelines for gender dysphoria care, allowing the anti-conversion therapy framework to “be reflexive and responsive to advances in scientific understanding and clinical best practice”. So, it seems the gender-affirming model is not, after all, the last word. Consistent with their inconsistency, the law reformers recommend that the chief psychiatrist draw up clinical guidelines in consultation with various expert bodies likely to disagree.
One such body is the Australian Professional Association for Trans Health (AusPATH); this is the gender-affirming guild, and it is devoted to the RCH guideline, which the hospital says has been “peer reviewed at the highest level”. Tasmania’s chief psychiatrist is also urged to consult the Royal Australian and New Zealand College of Psychiatrists. After a two-year review, the RANZCP decided not to reinstate its former unqualified endorsement of the RCH guideline, and noted the “paucity” of good evidence on the outcomes of “affirmative” hormonal and surgical treatments. The college pointed out that “evidence and professional opinion is divided” on the question whether the gender-affirming approach should even be used with children. AusPATH is not happy about the RANZCP rethink.
Tasmania’s chief psychiatrist is being lined up for an interesting job.
Ms Kyng’s new group, Active Watchful Waiting, takes its name from the “watchful waiting” approach which, until recently, was the standard, non-invasive response to young people — typically pre-school boys — who suffered severe distress over their birth sex, with the vast majority growing out of it and many emerging as gay or bisexual adults.
She said the qualifier “active” had been added to the term watchful waiting to make clear that the alternative to the gender-affirming mindset was not “a passive, apathetic approach” but a compassionate and exploratory intervention aimed at helping clients to arrive at the best outcome for them.
She said a wide range of techniques could be used, from cognitive behaviour therapy and trauma-informed care through dialectic behavioural therapy to family therapy.
The mainstream psychological argument against the politicised gender-affirming model is that it tends to uncritically accept a child’s trans or non-binary declaration, simplifying mental health problems as proof of a “transphobic” society, and downplaying the need to explore pre-existing and underlying issues such as trauma, same-sex attraction or undiagnosed autism.
Ms Kyng said low-quality evidence of suicide risk — self-reported data on suicide attempts among young people who identify as trans — was being recklessly used to pressure parents to go along with gender-affirming medical treatments.
“When we keep telling [trans-identified youth] that they're suicidal, we're spreading the contagion of suicidal ideation — and that's something we should never ever do. We would never do that in other areas of mental health care.
“It's unconscionable, spreading this narrative.
“We don't go around telling anorexics ‘You've got a really high suicide rate, you better make sure your parents let you do what you want to do’.”
Another familiar claim by trans rights activists — many of whom do not themselves identify as trans — is that the only sceptics of gender-affirming medicine are rightwing religious bigots.
“I’m a lifelong atheist,” Ms Kyng said. “I was raised by a Marxist, I'm married to a Marxist. I've always been a left-winger.”
She said Active Watchful Waiting was apolitical and secular as a group, and she believed in freedom of speech and religion.
“It’s not about left or rightwing. It's about evidence versus non- evidence, or evidence versus emotion.”
Therapists at the frontier
James Esses, an English trainee counsellor and former barrister, is crowdfunding a legal challenge after he was expelled from his psychotherapy course in May 2021. He had launched a public petition warning that the British government’s well-intentioned promise to ban conversion therapy might in fact be to the detriment of vulnerable children with gender dysphoria if, in practice, it criminalised “essential, explorative therapy”. Esses says his petition triggered a social media backlash and led to his expulsion. The petition, with more than 11,000 signatures, elicited a response from the government promising to ensure that the ban would “not impact on the independence and confidence of clinicians to support those who may be experiencing gender dysphoria”. Esses had a preliminary hearing in his increasingly complex case in February, and has lifted his fundraising target to £120,000. GCN sought comment from the psychotherapy training institute.
Thoughtful Therapists: “We have come together in a bid to protect the integrity of the open-ended exploration of feelings and ideas that has always been, and is still now, a necessary component of ethical and effective therapy.”
This group covering the UK and Ireland was active in the successful campaign to make the British government think twice about conflating sexual orientation and “gender identity” in its bill to outlaw conversion therapy. A ban on attempts to change sexual orientation will go ahead, but without seeking to protect gender identity. How best to respond to distressed minors who declare a transgender or non-binary identity is the subject of intense debate and an independent inquiry under former paediatrician Dr Hilary Cass.
Nikki da Costa, the former director of legislative affairs for the British prime minister, had warned that the original bill could have had profound, unintended consequences for children and adolescents diagnosed with gender dysphoria.
“It would create a situation where doctors, therapists, even parents, would be deterred from exploring with a child any feelings of what else may be going on for fear that they will be told they are trying to change a child’s identity,” she told BBC Radio 4.
However, UK psychotherapists still have to contend with a poorly defined Memorandum of Understanding on Conversion Therapy in which sexual orientation (including “asexuality”) and gender identity are jumbled together, making it unclear when ethical practices might be deemed career-ending.
Gender Exploratory Therapy Association: “Individuals who are exploring gender identity or struggling with their biological sex should have access to therapists who will provide thoughtful care and tend to legitimate mental health concerns, without pushing an ideological or political agenda.”
GETA is an international project that pushes back against the near monopoly of “affirmation-only” practitioners. It brings together licensed professional counsellor Sasha Ayad and Jungian analyst Lisa Marchiano from America, the English psychoanalytic therapist Susan Evans, psychiatrist Roberto D’Angelo from Australia, and Ireland’s psychotherapist Stella O’Malley. The association’s statement of values holds that psychological approaches should be the first-line treatment for gender dysphoria, and that medical transition of children and teenagers is experimental and to be avoided. GETA is in the early stages of building an international directory of like-minded therapists, conscious that parents seeking to protect gender-questioning children from medicalisation have great difficulty finding counsellors who will go deeper than immediate affirmation.