Bait-and-switch
The rise of gender medicine is a story of brilliantly executed identity politics and invasive treatment unjustified by short-term consumer satisfaction, according to Dr Stella O’Malley, the Irish psychotherapist who founded Genspect.
She said the hormonal and surgical interventions now marketed as “gender-affirming care” became the go-to response for youth gender distress despite the absent evidence of long-term benefit.
Like frontal lobotomies, medical transition should be judged “a failed intervention” alien to genuine healthcare, which has a duty to offer vulnerable people treatment directed at long-term improvement and recovery, Dr O’Malley said on Saturday at the second annual summit of the Coalition Advancing Scientific Care in Adelaide, Australia.
She said the success of the political campaign to depsychopathologise transgender identity as a healthy human variation had created a paradox: “Psychiatry removes the pathology while medicine intensifies the intervention.”
At its Gender Healthcare Summit, CASC announced an award for Australian whistleblower psychiatrist Dr Jillian Spencer, who was recognised for her courage in defending vulnerable children and evidence-based medicine.
One of these things is not like the other
Dr O’Malley noted that in the mid-1990s, LGBT emerged as an expanded entity when the T was piggy-backed onto the LGBs.
“It was an absolutely brilliant political campaign,” she said. But this merger conflated two starkly different imperatives.
“Gay rights sought freedom from psychiatric and medical interventions,” Dr O’Malley said. “Trans activism sought access to medical interventions while simultaneously arguing that transgender identity was not pathological.”
And, she said, those trans interventions simply did not work, judging by real-world outcome measures such as suicide risk, mortality, dependence on specialist psychiatric attention, family relations, employment and residential stability. Improvement on measures like these is expected of normal healthcare.
Yet the thread running through the history of gender medicine is one of “elevated mortality, elevated suicidality, elevated homelessness, elevated psychiatric care—but the patient is happy,” said Dr O’Malley, who recently completed her doctoral research on parents’ perceptions of youth gender dysphoria.
(Note: The remarks in italics, interspersed throughout the article below, were taken from summit presentations other than Dr O’Malley’s.)
British neuropsychologist Professor Sallie Baxendale on brain science relevant to the choices of gender-distressed youth: “[Adolescents] tend to live in the present, caring little for the future, and are prone to take risks. So, between about 10 and 19, you’ve got this mismatch between [teens] really looking for sensation and the ability to regulate themselves … ”
“[When talking to adolescents who want medical transition] you can go on and on about long-term health difficulties, it’s not going to hit home … But young people do not like to be manipulated … [It may be better to talk about] Big Pharma—who’s benefiting from putting somebody on a lifelong medical path?”
Bad theory: Irish psychologist and lecturer Ian Cox talks to Dr Stella O’Malley about a crisis in therapy and the academy
Worse after treatment
At the Adelaide CASC conference, Dr O’Malley cited an illustrative case dating back to the genital surgery experiments of 1930s Berlin. As Lili Elbe, a Danish man underwent a series of surgeries and declared his post-transition period to be “a whole and happy human life”. In 1931, three months after a fourth procedure, he died at 48 following surgical complications.
America’s trans surgeons came to the field later. In 1966, Johns Hopkins Hospital opened the first university clinic offering sex-reassignment surgery. Stanford University and others followed, marking an American heyday for “sex changes,” Dr O’Malley said.
She said the theme of subjective success and objective failure continued, as exemplified by the 1988 study by Bram Kuiper and Dr Peggy Cohen-Kettenis, as well as Kuiper’s 1990 dissertation follow-up in the Netherlands.
Of the 141 adults in this Dutch study, 16 suicide attempts were reported after the start of treatment. At follow-up, 11 of the 105 male-to-female patients had died (one by suicide), rising to 12 by 1995; a death rate of 11.4 per cent.
“This was far from [unregulated] affirmative care, and yet still we’ve got an 11.4 per cent [death rate],” Dr O’Malley said. “Don’t forget, not everybody got medical transition. You had to go through a lot of hoops to get it. They picked the people that were most suited back then.”
Kuiper’s 1991 dissertation noted complications such as fistulas, vaginal problems, pain and urinary difficulties. In a “loss to follow-up” characteristic of gender medicine, only 69 of the original 141 patients responded to the questionnaires. The adults not included in the study might well have had even poorer outcomes than those who did respond.
Yet Kuiper declared there was “no reason to doubt the therapeutic outcome”, and the earlier paper written with Dr Cohen-Kettenis claimed that treatment was “therapeutically effective”.
Australian clinical psychologist Dr Rachel Hannam: “When did distress reduction become the overriding objective when that distress pertains to gender? Of course, human rights matter; that’s not up for question. But psychology looks at pain. We have deeper questions [when a young person presents with gender distress].”
“What’s really happening? What response will help this person in the long run? Human rights principles protecting people from disrespect have now become clinical rulings about what distress means. ‘Don’t shame this young person’ becomes ‘do not inquire’. It’s become morally suspect to ask questions and inquiry has been shut down.”
Hard times
As for America’s sex-change heyday, Dr O’Malley said the emerging objective data proved to be discouraging, no matter how happy the patients reported themselves to be.
After a 1979 review, the Johns Hopkins researchers declared that trans surgery “offered no objective advantages in terms of social rehabilitation, although it remains subjectively satisfying to those who rigorously pursued a trial period and who have undergone it”. The clinic was shut down.1
Two years later, Dr O’Malley noted, the US Department of Health and Human Services advised that trans surgery should not be covered by Medicare. Its 1981 report said—
“Transsexual surgery for sex reassignment of transsexuals is controversial. There is a lack of well controlled, long-term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism. There is evidence of a high rate of serious complications of these surgical procedures.
“The safety and effectiveness of transsexual surgery as a treatment of transsexualism is not proven and is questioned. Therefore, transsexual surgery must be considered still experimental.”
That caution was overthrown in 2014.2
Clinical psychologist Dr Vanessa Spiller on how parents can protect their children from ill-considered social transition at school: “One of the things I do know about schools, particularly in Australia, is they are very risk averse. [I suggest you] at least raise in their mind that liability risk. They will have a two-page risk assessment for a pair of scissors in the classroom, and yet they will have no problem at all implementing these incredibly complex social transitions.”
Back from the brink
Dr O’Malley spoke of how politics rescued trans medicine from adverse policy and loss of funding.
In 2007, the Harry Benjamin International Gender Dysphoria Association—named for a German-born American endocrinologist with links to Berlin’s Institute for Sexual Science—was rebadged more attractively as the World Professional Association for Transgender Health.
“Despite no long-term replicable evidence to support medical transition, WPATH [in 2010] formally called for worldwide depathologisation,” Dr O’Malley said. “This was a political move.”
By 2013, the DSM diagnosis of “gender identity disorder” was supplanted by the supposedly less stigmatising “gender dysphoria”. A year later Time magazine heralded the Transgender Tipping Point, with Laverne Cox, a male-to-female actor, on the cover.
Around the same time, referrals at paediatric gender clinics began to grow exponentially, with teenage females overrepresenting in caseloads.
“The social contagion, I think, happened accidentally,” Dr O’Malley said. She points the finger at smartphones and social media.
“I don’t think anybody orchestrated that. It became bigger than activists had ever imagined—but they had depathologised the identity, they had made it normal and kind of cool.
“Young people are interested in cerebral concepts [and it’s] very alluring to think that ‘I could be a different person with a different body and a different name’.”
Australian Emeritus Professor of Law Patrick Parkinson: “We have reason to believe that while clinicians routinely discuss fertility preservation, they do not routinely explain the adverse impacts of cross-sex hormones on sexual function and capacity for sexual pleasure.”
“This is typically because these matters are too far beyond the contemplation and life experience of young patients who are often struggling with other mental health issues. [Clinicians] may be liable for a failure to give proper advice on the advantages and disadvantages of the treatment if subsequently, a person who regrets the treatment persuades a court that he or she would not have gone ahead with it had that advice been given.” His full paper is here.
Dollars and sense
In 2016, WPATH proclaimed its doctrine of medical necessity. Dr O’Malley said trans identity might have become “completely healthy and normal, but it also needs medical treatment. Why? They needed insurance”. It was a financial necessity.
In 2018, the World Health Organization’s ICD diagnostic system pushed depathologisation further. Now “gender incongruence”, without the distress necessary to gender dysphoria, was supposed to justify medical interventions.
Meanwhile, Dr O’Malley said, gender-affirmative ideas had been penetrating child psychotherapy and schools “without any supporting evidence”.
“How did we come to a point where, after all these failures in adult transition, we decided to move into paediatric transition?” she asked.
In part, she said, it was the idea that if there were such a thing as a trans adult, there must also be a trans child.
The puberty blocker-driven treatment of “juvenile transsexuals”, introduced by the famous Amsterdam clinic, was reportedly ventured in the belief it would prevent the poor outcomes seen in adult patients, especially males, who transitioned after a normal puberty.
Here was another contradiction, raised on the conference floor by paediatrician Dr Dylan Wilson. If the Dutch acknowledged the dissatisfaction of their previous, adult patients, were they contradicting the upbeat message of their own research?
Dr O’Malley said she believed the Dutch clinicians would have been aware that “the rates of mortality and suicide [among adult patients] were worrying, and so they needed to think, ‘what is wrong?’ And rather than stopping, changing and offering other interventions, they chose to treat children.”
This, she said, was “a wildly inappropriate decision”.
UK Tavistock clinic whistleblower and psychotherapist Marcus Evans: “The affirmation model is a pain avoidance technique. You just go along with the kid … [Therapy] is difficult if the child feels they’ve got a solution to their psychological pain … ”
“[There can be] collusion between the clinician and the patient on a pain-free solution … They don’t have a mind capable of dealing with the sort of ordinary pain, disappointments, anxieties, conflicts that are going to help you in the adult world. That’s what you're going to need in terms of your equipment. You’ve got to be able to suffer a bit.”
Anything goes
By 2022, when WPATH released its latest standards of care, “safeguards had largely disappeared,” Dr O’Malley said. Minimum ages were abandoned for minors to be eligible for hormonal and surgical treatment.
Gender medicine had shifted “from medical diagnosis to civil rights. Psychiatric ‘gatekeeping’ was identified as a principal obstacle [to treatment],” Dr O’Malley said.
“It was a political campaign, and it was very well executed.
“Objectives changed from improving clinical evidence to securing access [to treatment] through self-declaration.
“The language of identity, stigma, discrimination and civil rights was adopted. Medical transition became framed as a human right rather than experimental medical treatment.
“Transition has moved from rare experiment to presumptive treatment, without establishing reliable evidence of long-term benefit.”
An Australian mother from Parents of Adolescents with Gender Distress: “Coming from Victoria, where we have some of the worst ‘conversion therapy’ laws in the country, it’s had an absolutely catastrophic effect on being able to find neutral supportive therapy … It would be just great to see therapists who have the confidence to actually look past the gender and look at all the other stuff that’s going on.”
Wait, what?
What longitudinal research there was should have given clinicians pause for thought, according to Dr O’Malley.
She cited a sobering Swedish study, which had comprehensive coverage of those who had transitioned, something rare in the gender medical field with its missing ex-patients.
The 2011 paper, with Dr Cecilia Dhejne as first author, reported on all 324 adults who had undergone “sex-reassignment” in the country between 1973 and 2003.
After treatment, they had a suicide rate 19 times that of matched controls in the general population. Overall mortality, suicide attempts, psychiatric hospitalisation—all these were elevated when compared with the rest of society.
A striking, more recent study from Finland—highlighted by Dr O’Malley—found that young people under 23 were not doing well after transition. Again, this was a study using complete health register data, and therefore unaffected by the familiar loss-to-follow-up problem.
The resulting 2026 paper by Dr Sami-Matti Ruuska and colleagues reported that severe psychiatric morbidity among these young males rose from 9.8 per cent to 60.7 per cent after transition. For females, this morbidity increased from 21.6 per cent to 54.5 per cent.
Dr O’Malley’s conclusion: “Medical transition is a failed intervention. Across several decades, patient satisfaction coexisted with continuing or increased psychiatric, social and physical problems, as well as elevated mortality and suicidality.”
“Can we now go back to the drawing board, start looking at the objective long-term outcomes, for this pseudo-healthcare—and realise it’s not healthcare, it’s consumerism, and it’s destructive.”
Associate Professor Karleen Gribble on the gender-driven corruption of language and sex data: She cited data from the Australian Institute of Health and Welfare to the effect that from 2015-16 to 2024-25, 167 penises had been amputated … from females. In Australian data, the sex marker field has become unreliable because of self-declared gender identity.
Bedazzled
Dr O’Malley said that, especially early on, when eligibility for transition was more restricted, gender clinics “were offering a bedazzling, beguiling, alluring treatment to people who really wanted it”.
“The idea of healthcare is something ethically more responsible than consumerism,” she said. The fact that patients declare themselves happy soon after harmful gender treatment is not enough. Anorexics celebrate weight loss, Dr O’Malley pointed out. And there are compulsive alcoholics.
“There’s a lot of people who want something that isn’t good for them in the long term,” she said. “We can offer them a lot of really good, compassionate, careful, comprehensive treatment.”
“That doesn’t mean that we absolutely yield to the fact that what they want is what they should get. Arguably, consumer-driven healthcare has brought us to this place.”
She said patient-centred care had become patient-led, even child-led—another “seismic move”. And many therapists were abdicating their responsibility as if there were no shared outcomes such as a patient’s recovery or some improvement in life.
“You’re not going to therapy for me to just nod along to you—I’m not a nodding dog,” Dr O’Malley said.
She said the purpose of Genspect’s own repathologisation campaign—viewed by some as a mistaken move—was to restore a psychological approach and the hope of recovery to gender distress.
“We’re not interested in repathologising gender nonconformity,” she said. “We’re not interested in repathologising anything that doesn’t meet certain criteria for pathological behaviour.”
For Genspect, someone who seeks “medical alteration of sex characteristics” has a mental disorder falling into the category of an “overvalued belief”.
“We’re utterly unapologetic about it,” Dr O’Malley said. “We’re very clear. We’re offering a psychological approach. We believe this is a psychological issue, and this needs a psychological approach.”
“We’re offering what we would consider calm, compassionate, long-term care, rather than a flurry of medical interventions with a lot of pressure on the individual.”
In Dr O’Malley’s Ireland, there has been an activist push for draconian laws against so-called conversion therapy. Many jurisdictions elsewhere have already legislated penalties that make it risky to engage in normal exploratory psychotherapy with a confused child.
“Now we’ve kind of moved into a world where I’m being told wanting to help a person genuinely isn’t appropriate,” Dr O’Malley said. Instead, she said, the favoured affirmative handling of gender distress was akin to a “quick soundbite—patient is happy six months after treatment. Go, go, go”.
“And that’s where we’ve lost our way.”
The clinic was reopened in 2017. Professor Paul McHugh, who was Psychiatrist-in-Chief of Johns Hopkins Hospital at the time of the clinic’s closure, remains a critic of the transgender idea. In 2019, he told The Australian newspaper that “psychiatry is usually good, but every 10-15 years it gets lost in some misadventure”.
In President Obama’s second term, the exclusion of trans surgery from Medicare was ended. In President Trump’s current term, the Centers for Medicare & Medicaid Services has announced a rule that would stop the use of federal Medicaid and the Children’s Health Insurance Program for “sex-rejecting procedures for children and youth”. The rule took effect from October 13, 2026, although it is under legal challenge.