Here are comments from anonymous reviewers for the journal.
Reviewer: 1
Comments to the Corresponding Author
Overall, there are several major issues with this manuscript including the lack of evidence used to make very significant claims e.g., the use of one case study, and lack of inclusion of the significant amount of research that finds GAMT to be beneficial to the mental health of trans people including adolescents. Suggesting that GAMTs are iatrogenic and that the RANZCP claim 'culpability' without a significant, thorough and deeply critically engaged research methodology is disturbing with the possibility and probability of causing a high degree of harm to the already disproportionately targeted trans and gender diverse population. Furthermore, some of the extant research has been misread and used to reflect findings incorrectly, and additionally, considering the claim that medical professionals who provide GAMT are "driven by ideology", there is a noted lack of stated reflection about how the authors paradigm impacts their claims and findings.
To elaborate I will provide more detail on a few of these points. Firstly, the authors suggest that adolescents are transgender due to a lack of "mentalizing" skill or ability and the absence of authority figures that assert or reinforce the youth is cisgender. In Australia and most other Western countries governed by the Diagnostic Statistical Manual, gender dysphoria and transgender as a gender identity are not seen as mental illness or symptom of a mental health condition, nor specifically due to a mentalization deficit. Secondly, regarding the role of psychiatric and parental figures in relation to providing health care for trans and non-binary individuals, the authors assert the it is the lack of "authority" from and by said figures, that prevents adolescents from being influenced into what they claim is an 'unnatural' or 'fictional' gender identity. Furthermore, they provide the term "transgender influencers" to reference individuals who tell "positive stories about gender affirming care" suggesting they do so with the aim of encouraging transition. They cite Selkie, Ellen et al. as the source of this information. The study by Selkie, Ellen et al. examines the role of social media use by a select group of adolescents in a rural US region. The study found social media use was an effective measure in relation to preventing and reducing mental health disparities for trans adolescents in that rural location, not that as the authors claim, social media use increases mentalizing issues leading to adolescents mistakenly thinking they are transgender.
Reviewer: 2
Comments to the Corresponding Author
Given the manuscript’s significant flaws, I strongly recommend against publication.
The manuscript is rife with mischaracterizations and bold claims unsupported by arguments. For instance, the author grossly oversimplifies arguments in favour of gender-affirming care as “the claim that children know who they are,” and then insists that it is “an ideological assertion that is inconsistent with all existing models of human development” without offering nearly adequate support for so bold an assertion. The author similarly comments that it is false “that gender interventions reduce suicide risk,” relying on a single controversial governmental review that some have claimed is fundamentally flawed. The author also presents select theories of child development and cognition as uncontroversial, failing to adequately explain and support them or compare them to competing theories. These problems recur throughout the article, making it read far more like a political tract than a rigorous academic essay. The “suggested RANZCP acknowledgement of culpability and apology” makes clear that this is indeed the case.
Despite the fact that the question at the heart of the manuscript—gender-affirming care for minors—turn in significant ways on medical ethics and neuroscience, the author does not draw on the extensive literature of both disciplines, nor seriously engage with the numerous articles that have been published on this specific question.
In addition to these substantive issues, the manuscript is poorly written. The author does not properly introduce the article’s thesis nor signpost its structure. The manuscript is meandering and difficult to follow, lacking structure. Given all the foregoing, publishing this manuscript would risk embarrassment for the journal.
May have been unaware of the systematic reviews undertaken by faculty colleagues… in activist mode, in any case, where one seemingly promising study is enough for the vibe.
It would be instructive to share the reviewers comments, much in the same way that it was illuminating to read the exposed private WPATH ravings that displayed the rank ignorance of the so-called gender affirming care practitioners.
The research and examination of available research, questioning the findings and answering to the facts, and postulating improvements based on those facts.
This is an excellent paper and deserves to be published.
I hope we share the heck out of it, and that it is gathered up and published in a more influential publication.
Thank you to the writers and thank you for publishing here, BL and GCN.
If the author grossly oversimplifies arguments in favour of gender-affirming care as “the claim that children know who they are,” what are the less simplified arguments to support GAC?
That heavy hitter D. Ehrensaft, would have them as affirmation as suicide prevention, developmentally appropriate support, parental and clinical collaboration, authenticity and flourishing...weighty, irrefutable and beyond discussion?
The anonymous reviewers of this article exhibit all of the insights of the dullard brand managers who currently prevail in this space; their virtue hoarding is supercilious and tragically antisocial.
This is a very good and well written paper. But it is asking doctors to apologise for not treating these vulnerable young people properly. This is something they avoid at all costs. Sadly it costs the lives of these vulnerable young people as they navigate life and face a very damaged future.
This kind of hubris is very prevalent amongst the health professionals in many areas.
As per the link above EBM is a tiered system which has five levels. Tie1 is, of course the highest order and thus the most effective and safe therapies.
One would expect that an invasive, irreversible, sterilising procedure involving children would Tier 1. Not so, according to the criteria the ‘Affirmative Model of Gender Care’ would satisfy Level 3 – A totally unacceptable level for what is being done to these children!
. . . .However it doesn’t finish there, the well documented very poor long-term outcome (30 plus years – see references below) will impact the evidence base to well below level 3.
Very poor outcomes from a therapy negatively impact its evidence base by revealing limitations in the treatment, highlighting the need for better patient-therapist matching, or indicating that a different therapeutic approach is required.
To remind readers of a few of the long-term outcome following gender transition I reference 3 of the many studies with a very brief summary. These studies are readily available on the internet:
1. Transition as Treatment: The Best Studies Show the Worst Outcomes
• Key Findings: Total mortality was 51% higher than in the general population, mainly from suicide, AIDS, CVS diseases, drug abuse and unknown causes.
2. Long-Term Follow-Up of Transsexual Persons Sweden (1973– 2023)
• Key Finding: Individuals who underwent sex reassignment surgery exhibited substantially higher risks of mortality, suicidal behaviour and psychiatric conditions compared to the general population.
3 . Somatic Morbidity and Cause of Death in Denmark (1978–2010)
• Key Finding: Among individuals who underwent GT, somatic morbidity increased from 19.1% pre-surgery to 23.2% post-surgery
“ The longer the beast is not challenged, the stronger it becomes “, it’s hard to think of a better example of the aphorism. The authors of this , directly confronting demand for an apology might however consider the other key players in G.A.C., when we are referring specifically to minors, than just the psychiatrists. The paediatric endocrinologists and surgeons have delivered the “ hands on” medical intervention components of G.A.C. and surely deserve an equivalent opprobrium. Their specific acquiescence is obligatory to implementing the medical intervention components of G.A.C. The Social Sciences, I.e., the clinical psychologists,who started it all, and have been clinical leaders at the gender clinics, Polly whatshername ( Carmichael?) a psychologist, was , i understand, the senior clinician at Tavistock, while the staff paediatricians were subservient it seemed. These powerful folk should not get away with pleading the ignorance of not receiving their medical colleagues training, to be able to let them have “ gender identity “ trump biology, but that was the genie who first got out of the bottle , and shamefully, it continues to receive support from members of the medical scientific community. Such , though medically trained clinicians have been prepared to fight harder to protect this “ beast” from challenges.
Ideologies, like religions, when they become pernicious and dangerous, prove difficult opponents.
Here are comments from anonymous reviewers for the journal.
Reviewer: 1
Comments to the Corresponding Author
Overall, there are several major issues with this manuscript including the lack of evidence used to make very significant claims e.g., the use of one case study, and lack of inclusion of the significant amount of research that finds GAMT to be beneficial to the mental health of trans people including adolescents. Suggesting that GAMTs are iatrogenic and that the RANZCP claim 'culpability' without a significant, thorough and deeply critically engaged research methodology is disturbing with the possibility and probability of causing a high degree of harm to the already disproportionately targeted trans and gender diverse population. Furthermore, some of the extant research has been misread and used to reflect findings incorrectly, and additionally, considering the claim that medical professionals who provide GAMT are "driven by ideology", there is a noted lack of stated reflection about how the authors paradigm impacts their claims and findings.
To elaborate I will provide more detail on a few of these points. Firstly, the authors suggest that adolescents are transgender due to a lack of "mentalizing" skill or ability and the absence of authority figures that assert or reinforce the youth is cisgender. In Australia and most other Western countries governed by the Diagnostic Statistical Manual, gender dysphoria and transgender as a gender identity are not seen as mental illness or symptom of a mental health condition, nor specifically due to a mentalization deficit. Secondly, regarding the role of psychiatric and parental figures in relation to providing health care for trans and non-binary individuals, the authors assert the it is the lack of "authority" from and by said figures, that prevents adolescents from being influenced into what they claim is an 'unnatural' or 'fictional' gender identity. Furthermore, they provide the term "transgender influencers" to reference individuals who tell "positive stories about gender affirming care" suggesting they do so with the aim of encouraging transition. They cite Selkie, Ellen et al. as the source of this information. The study by Selkie, Ellen et al. examines the role of social media use by a select group of adolescents in a rural US region. The study found social media use was an effective measure in relation to preventing and reducing mental health disparities for trans adolescents in that rural location, not that as the authors claim, social media use increases mentalizing issues leading to adolescents mistakenly thinking they are transgender.
Reviewer: 2
Comments to the Corresponding Author
Given the manuscript’s significant flaws, I strongly recommend against publication.
The manuscript is rife with mischaracterizations and bold claims unsupported by arguments. For instance, the author grossly oversimplifies arguments in favour of gender-affirming care as “the claim that children know who they are,” and then insists that it is “an ideological assertion that is inconsistent with all existing models of human development” without offering nearly adequate support for so bold an assertion. The author similarly comments that it is false “that gender interventions reduce suicide risk,” relying on a single controversial governmental review that some have claimed is fundamentally flawed. The author also presents select theories of child development and cognition as uncontroversial, failing to adequately explain and support them or compare them to competing theories. These problems recur throughout the article, making it read far more like a political tract than a rigorous academic essay. The “suggested RANZCP acknowledgement of culpability and apology” makes clear that this is indeed the case.
Despite the fact that the question at the heart of the manuscript—gender-affirming care for minors—turn in significant ways on medical ethics and neuroscience, the author does not draw on the extensive literature of both disciplines, nor seriously engage with the numerous articles that have been published on this specific question.
In addition to these substantive issues, the manuscript is poorly written. The author does not properly introduce the article’s thesis nor signpost its structure. The manuscript is meandering and difficult to follow, lacking structure. Given all the foregoing, publishing this manuscript would risk embarrassment for the journal.
wow. quoting an individual study in response to systematic reviews. right.
May have been unaware of the systematic reviews undertaken by faculty colleagues… in activist mode, in any case, where one seemingly promising study is enough for the vibe.
It would be instructive to share the reviewers comments, much in the same way that it was illuminating to read the exposed private WPATH ravings that displayed the rank ignorance of the so-called gender affirming care practitioners.
Have added reviewer comments in this thread, Dianna. B
Excellent. This is science.
The research and examination of available research, questioning the findings and answering to the facts, and postulating improvements based on those facts.
This is an excellent paper and deserves to be published.
I hope we share the heck out of it, and that it is gathered up and published in a more influential publication.
Thank you to the writers and thank you for publishing here, BL and GCN.
If the author grossly oversimplifies arguments in favour of gender-affirming care as “the claim that children know who they are,” what are the less simplified arguments to support GAC?
That heavy hitter D. Ehrensaft, would have them as affirmation as suicide prevention, developmentally appropriate support, parental and clinical collaboration, authenticity and flourishing...weighty, irrefutable and beyond discussion?
The anonymous reviewers of this article exhibit all of the insights of the dullard brand managers who currently prevail in this space; their virtue hoarding is supercilious and tragically antisocial.
This is a very good and well written paper. But it is asking doctors to apologise for not treating these vulnerable young people properly. This is something they avoid at all costs. Sadly it costs the lives of these vulnerable young people as they navigate life and face a very damaged future.
This kind of hubris is very prevalent amongst the health professionals in many areas.
EVIDENCE BASED MEDICINE
https://www.ncbi.nlm.nih.gov/books/NBK470182/
As per the link above EBM is a tiered system which has five levels. Tie1 is, of course the highest order and thus the most effective and safe therapies.
One would expect that an invasive, irreversible, sterilising procedure involving children would Tier 1. Not so, according to the criteria the ‘Affirmative Model of Gender Care’ would satisfy Level 3 – A totally unacceptable level for what is being done to these children!
. . . .However it doesn’t finish there, the well documented very poor long-term outcome (30 plus years – see references below) will impact the evidence base to well below level 3.
Very poor outcomes from a therapy negatively impact its evidence base by revealing limitations in the treatment, highlighting the need for better patient-therapist matching, or indicating that a different therapeutic approach is required.
To remind readers of a few of the long-term outcome following gender transition I reference 3 of the many studies with a very brief summary. These studies are readily available on the internet:
1. Transition as Treatment: The Best Studies Show the Worst Outcomes
• Key Findings: Total mortality was 51% higher than in the general population, mainly from suicide, AIDS, CVS diseases, drug abuse and unknown causes.
2. Long-Term Follow-Up of Transsexual Persons Sweden (1973– 2023)
• Key Finding: Individuals who underwent sex reassignment surgery exhibited substantially higher risks of mortality, suicidal behaviour and psychiatric conditions compared to the general population.
3 . Somatic Morbidity and Cause of Death in Denmark (1978–2010)
• Key Finding: Among individuals who underwent GT, somatic morbidity increased from 19.1% pre-surgery to 23.2% post-surgery
“ The longer the beast is not challenged, the stronger it becomes “, it’s hard to think of a better example of the aphorism. The authors of this , directly confronting demand for an apology might however consider the other key players in G.A.C., when we are referring specifically to minors, than just the psychiatrists. The paediatric endocrinologists and surgeons have delivered the “ hands on” medical intervention components of G.A.C. and surely deserve an equivalent opprobrium. Their specific acquiescence is obligatory to implementing the medical intervention components of G.A.C. The Social Sciences, I.e., the clinical psychologists,who started it all, and have been clinical leaders at the gender clinics, Polly whatshername ( Carmichael?) a psychologist, was , i understand, the senior clinician at Tavistock, while the staff paediatricians were subservient it seemed. These powerful folk should not get away with pleading the ignorance of not receiving their medical colleagues training, to be able to let them have “ gender identity “ trump biology, but that was the genie who first got out of the bottle , and shamefully, it continues to receive support from members of the medical scientific community. Such , though medically trained clinicians have been prepared to fight harder to protect this “ beast” from challenges.
Ideologies, like religions, when they become pernicious and dangerous, prove difficult opponents.