On demand

Gender-affirming care is a political imperative, not medicine

Photo by Marcelo Leal on Unsplash

Andrew Amos

You’ve heard powerful first-hand accounts of the harms caused by “gender-affirming care” to patients, families and critics. My research has been focused on the health system failures that allowed these harms to happen and the missing safeguards that should have prevented them.

In modern health systems like Australia’s, the main safeguards are evidence and oversight. Evidence-based medicine means that patients are not treated unless there is strong evidence that treatment is likely to help and unlikely to harm them. Oversight means that health authorities are responsible for reviewing, endorsing and monitoring health systems over time to ensure that they are following evidence-based practice, and that they are actually helping and not harming patients.

To show that gender-affirming care fails to achieve these safeguards, I will outline a few underlying ideas.

The gender-affirming model of care describes how healthcare workers should manage gender-diverse patients, but those terms mean different things to different people. Here’s my understanding—

Until recently, very few people distinguished between biological sex and gender.

Biological sex can be understood as the physical features associated with sex chromosomes XY in males and XX in females, so this would include things like differences in height and weight, but also differences in behaviour, such as generally greater aggression in males.

Gender can be understood as the social experiences associated with the physical manifestations of sex, which would include the roles expected of males and females in social situations, and individuals’ responses to these.

“Gender identity” is the gender presented by an individual, with two main groups. Gender-traditional people think of gender as largely defined by sex, and this includes most people in most of the world. Gender-diverse people think of gender as unconstrained by sex, and this would include transgender people who present their gender identity as the opposite of their sex, although there are many other examples.

So, with those meanings in mind, gender-affirming care is a model adopted by many Australian gender services which assumes that gender diversity is a healthy variant of what is normal. The model denies that gender diversity involves mental illness. And it demands that healthcare workers affirm and do not question gender-diverse patients’ self-reported gender identities.

The model views access to social, medical and surgical interventions that reinforce gender diversity as a human right available to anyone who claims a non-traditional gender identity. And gender-affirming care recommends that social, medical and surgical interventions should be available even to patients with severe mental illness, such as schizophrenia.

The template for gender-affirming care for minors in Australia is the treatment guideline issued by the Royal Children’s Hospital (RCH) Melbourne and endorsed by the Australian Professional Association for Trans Health (AusPATH). The RCH guideline, in turn, is largely based on the standards of the World Professional Association for Transgender Health.

Politics, not medicine

The most important thing to realise about gender-affirming care is that it is not a medical model of care at all.

The medical model starts with the diagnosis of an illness by a doctor, who weighs the benefits and harms of treatment based on high-quality evidence, implements the treatment with the best balance for the patient and measures the results.

By contrast, the gender-affirming model of care fails to meet any of these conditions—

It doesn’t require a diagnosis to justify treatment, as it relies upon patients’ subjective reports, which healthcare workers are advised not to challenge.

It isn’t based on high-quality evidence, a fact which the RCH-AusPATH guidelines explicitly acknowledge, as they state that their recommendations are based on clinician consensus because of the absence of evidence.

Not only do the guidelines acknowledge the lack of evidence, they consider it unethical to look for high-quality evidence at all, which of course prevents the discovery of harms.

The guidelines never define the benefits of the interventions they recommend; they simply assume that the social, medical or surgical reinforcement of gender identity is good of itself, even in cases where a patient later reverts to a traditional gender identity.

So, if gender-affirming care is not a medical model of treatment, what is it?

We can see that in place of the diagnosis-treatment-measurement template of medicine, gender-affirming care is based on a political demand for the novel human right to define a gender identity unconstrained by biology, social conventions or stability.

As gender-affirming care denies that gender diversity involves illness, it extends the political demand for the right of self-definition to the right to social, medical and surgical interventions.

In this model, the healthcare worker’s only role is to provide information; they cannot question whether an intervention is likely to harm or benefit a patient.

Activist strategy

If it’s accepted that the gender-affirming standards insert a political demand into a medical protocol, it becomes obvious that this has a number of strategic advantages for transgender activists—

The insertion shields activists from public debate of the political demand; to make a comparison to a recent counter-example, the same-sex marriage debate was wide-ranging, public and ultimately confirmed by a plebiscite.

By presenting the political demand for recognition of gender diversity inside a medical protocol, activists have successfully avoided any debate of the political implications.

On the other side of this equation, by justifying intervention for gender diversity as a right rather than evidence-based treatment of a diagnosed illness, activists have been able to avoid producing evidence that their interventions are beneficial and not harmful.

Inserting the political demand into a medical protocol automatically leverages the authority of the medical profession and health systems in support of the gender-diverse model of human nature; in effect, it forces doctors and the health system to support a political agenda, and guarantees access to health and welfare resources.

Neglect and failure

When considering why this systemic failure happened, the main answer is that the relative neglect of other health professionals has allowed a small group of activists to dominate health system decisions about gender diversity.

A good illustration of this neglect is the fact that a number of medical authorities across Australia and the world are now starting to admit it was a mistake for them to endorse gender-affirming care.

In Australia, for example, the college of psychiatrists, which is my college, is responsible for training junior doctors to become psychiatrists and then for ensuring that consultant psychiatrists practice ethically and competently.

In the early days of the introduction of gender-affirming care to Australia, the college of psychiatrists issued a position statement endorsing the model. However, two years ago, the college removed that endorsement, acknowledging that there was no good evidence that gender-affirming care helps and does not harm patients.

Effectively, the college admitted that their original endorsement was illegitimate, putting patients and their families at risk.

From my involvement with the committees that constitute the college, it’s apparent that the original endorsement was driven by activists with an agenda, which was allowed to prevail because of the neglect of other members.

WHO are these experts?

The lack of public disclosure of college processes makes it difficult to conclusively prove what happened. However, there’s a perfect example of activist influence on the public record in the team put together by the World Health Organisation to develop guidelines for gender-diverse people.

Only two of 13 members of the guideline development group were doctors, both of whom are actively involved in the transgender movement. Eleven of the 13 were directly involved as representatives of trans or gay rights activist organisations. Five of the 13 had no primary medical or health degree or practice but were primarily employed as trans activists. (One of the original group of 14 dropped out or was removed.)

While it is certainly true that medical guidelines should seek input from stakeholders, this guideline development group is clearly at risk of subordinating medical goals and processes to activist goals and political agendas.

This example leads directly to the question of what harms can result from activist-driven healthcare without adequate oversight, and while it’s very difficult to get a clear idea what is happening in Australia’s gender services, we have a very good answer available in the UK’s Cass review.

The UK is a few years ahead of Australia in implementing gender-affirming care, and until recently the gender service at the Tavistock Institute handled most of this work. However, towards the end of the last decade there was a series of complaints by gender service clinicians about questionable practices, and a series of legal actions by patients and families claiming they’d been harmed by gender-affirming care at the Tavistock, and this led to the Cass review, which released interim results in 2022.

Diagnostic overshadowing

The Cass review confirms that activist-driven gender services operate without the usual safeguards of the medical model. To mention just a few of the missing safeguards, the lack of independent oversight contributed to a number of failures—

Treatments were not justified by evidence, which meant it was unrealistic to expect positive outcomes.

The service also failed to monitor outcomes, so it was unknown whether patients had benefited overall.

Perhaps the most concerning result was that clinicians at the service reported pressure to use a gender-affirming approach “at odds with the standard process of clinical assessment and diagnosis”, which, along with a failure to routinely assess mental health, meant it was highly likely that pathological causes of gender diversity were missed and therefore not treated.

The review noted the related phenomenon of “diagnostic overshadowing,” where other health and mental health issues were ignored after gender distress was identified.

The risk of patient harms revealed by these concerns was so significant that it was decided to shut down the Tavistock gender service pending further review.

The lack of safeguards for gender-affirming care leads to obvious potential harms, including—

Patients who risk alienation from their families and social networks, disrupted social development, infertility, sexual dysfunction, depression and suicide, among other harms.

Next most affected are families, particularly by the disruption of family bonds, the burdens of unnecessary care, and distress caused by the harms to patients.

Special mention should be made of the impact on the courts, which have made a number of decisions based on a standard of care that is now being rejected by medical authorities, and which may therefore need to be revisited.

The failure of the medical profession to fulfill their responsibility to oversee the care of gender diverse patients threatens to damage its reputation with the public and to decrease patient trust.

What to do?

In my opinion, the solution is for medical authorities to accept their responsibility for the safe and ethical care of patients and to insist on the assertion of the usual safeguards of evidence and oversight.

As a consequence, interventions for gender diversity must be suspended until there is high-quality evidence that they benefit and do not harm patients. This will obviously require the initiation of high-quality research to properly test the claims of gender-affirming care. Governments and medical authorities must ensure that both research and medical protocols are confirmed by independent actors without conflicts of interest.

As a final point, I propose that the political demand for recognition of gender diversity cannot be resolved in the medical domain—it must be resolved through public debate and the political process.

Dr Andrew Amos is an Australian academic psychiatrist. This is an edited text of his presentation to a forum, The Unheard Voices, held at Parliament House, Sydney, NSW, on February 6