The profession that failed

The college of psychiatrists in Australia and New Zealand should apologise for the harm done by paediatric medical transition

Relations between parents and their children have been put under strain by the failure of psychiatry to challenge ideological “gender-affirming care”. Photo by Transly Translation Agency on Unsplash

This article was offered to but rejected by the journal Australasian Psychiatry, a publication of the Royal Australian and New Zealand College of Psychiatrists. One of the anonymous reviewers of the article protested its “lack of inclusion of the significant amount of research that finds [gender-affirming medical treatment] to be beneficial to the mental health of trans people including adolescents.”

The commenter was silent on the quality of that research. Another reviewer complained that the article “grossly oversimplifies arguments in favour of gender-affirming care as ‘the claim that children know who they are’.” The Weekend Australian newspaper has reported the story of the article’s rejection here.—BL

Drs Jillian Spencer, Roberto D’Angelo and Patrick Clarke

Child psychiatry is underpinned by a developmental perspective. This involves understanding a child’s or adolescent’s emotional experience, behaviour and thinking in the context of their developmental trajectory, rather than simply their chronological age.

Child psychiatrists draw on a range of developmental theories when working with children and adolescents. Historically, individuation and the formation of identity have been viewed as the main developmental tasks of adolescence. These earlier theories, however, minimise or overlook attachment and relatedness during adolescence, which are now seen to be equally crucial. The emotional availability of the caregiver is the foundation on which separation occurs. Adolescents are also faced with the challenge of developing and maintaining more complex relationships. Adolescents are driven to individuate and connect but need to achieve this within the confines of societal expectations.

Fonagy et al propose that a key aspect of human psychological development is the capacity for mentalization, which involves the perceiving and understanding of human behaviour in terms of intentional mental states. Mentalization is the ability to understand one’s own and others’ mental world, such as intentions, beliefs, emotions and desires, and how these may influence a person’s behaviour. Mentalization is essential for affect- and self-regulation but also for the development of identity. It is the foundation of self-awareness, the capacity for relatedness, and for the integration of experiences into a coherent sense of self. Identity is a theory or narrative about oneself, developed by exploring alternatives and gradually establishing roles, responsibilities and relationships. The process of identity formation continues well into the mid-twenties.

Adolescents are faced with increasingly complex social, relational, sexual and intellectual demands. The increasing importance of extra-familial relationships makes them vulnerable to peer pressure to conform and fear rejection. At the same time, they develop the capacity for abstract thinking, which means that the world and relationships are experienced as more complicated and confusing. Mentalizing can become overwhelming and activities such as internet surfing, social media or music provide a reprieve. They may regress into a thoughtless, self-centred mode when the strain of increasingly complex mentalizing overwhelms their evolving capacities.

If the adolescent’s capacity for mentalizing collapses, she or he may regress to non-mentalizing modes of thinking. These include the “psychic equivalence mode” where a feeling or thought is experienced as reality, and no other perspective can be entertained; and the “teleological mode” in which mental states are expressed in actions rather than verbally represented. Further, it has been proposed that brain processes such as synaptogenesis and synaptic pruning result in a temporary disruption of mentalizing skills in adolescents, the so-called “pubertal dip”.

This instability of mentalizing capacities and the switch to non-mentalizing modes can lead to the frequently observed emotional volatility and erratic behaviour seen in adolescents. It may manifest as impulsive behaviour, risk-taking that ignores potentially harmful consequences, sensation seeking and an inability to resist peer pressures. Adolescents with histories of adversity, such as early attachment difficulties, adverse childhood experiences or neurodevelopmental disorders are likely to be particularly vulnerable to the loss of mentalizing capacities. Their limited capacity to form supportive connections may lead them to seek out others, especially online, who suffer from similar problems.

Boundaries

The developmental perspectives outlined above facilitate an understanding of the central importance of a network of authority figures around adolescents to provide limits on their behaviour—so-called boundaries—for their protection. Adolescents may exhibit anger or distress in response to boundaries imposed. Such responses may represent a testing of the relationship with the authority figure to gain reassurance that the parent/attachment figure remains connected and protective.

As explained above, impaired mentalizing can make it difficult for an adolescent to resist impulsive action or pressure from peers. It may manifest as over-confidence and recklessness, or as approval-seeking from idealised peers. Identification with problematic figures such as friends, celebrities or online influencers that sanction risky or antisocial behaviours can occur. Consequently, parents and authority figures need to provide a safeguarding function to protect adolescents from permanent consequences of poor decisions, while also providing mentalizing capacities when these are temporarily offline for the adolescent.

Authority figures should ideally facilitate the adolescent’s exploration with a gradation of successful steps towards individuation. Adolescents may also benefit from uncomfortable short-term frustration or the consequences of their actions. Experiences such as social embarrassment, teacher opprobrium and school-based punishments, unrequited love and rejection, parental disciplinary measures such as losses of privileges and potentially even minor criminal sanctions are examples of helpful normative boundaries upon adolescent behaviours.

The psychic equivalence mode proposed by Fonagy et al is an elaboration of the psychoanalytic concept of infantile omnipotence. Omnipotence is a state of mind where the child believes that they have control over their world and that their thoughts and wishes will determine reality. Limit-setting is important in helping the child relinquish omnipotence and develop the capacity to mentalize.

Challenges of parenting

Modern society is characterised by the dismantling of tradition and any form of authority in favour of individualism and a horizontal social structure where all possibilities are equally valid. The freedom to make one’s own choices may increase the uncertainty and difficulty of making them, especially when compared with the simplicity of following tradition or religious or other authorities that pre-establish the aim of life and the way to attain that aim.

This is a drastic revision of the social order in which all authority is seen as limiting and oppressive. Clinical experience suggests that parenting practices have adopted this new paradigm in many cases. In these families, parents are reluctant to impose limits or maintain boundaries and may inadvertently perpetuate infantile omnipotence. The challenge is to strike a balance between boundaries, on the one hand, and respect for freedom and individuality on the other. Unquestioning affirmation of a child’s gender identity has emerged in this context, where the child is now seen as having legitimate authority over their body and life, and the authority of parents has been eroded. Parents who do not align with affirming a child’s gender are cast as transphobic.

Modern environmental factors are also significant, such as social media facilitating the rapid communication of ideas between adolescents. Transgender influencers use social media to disseminate positive stories about gender-affirming care that encourage transition. The transgender movement provides an explanation for the discomfort associated with the overwhelm of adolescence, while promising the hope of connection and belonging. Adolescent discomfort is normative but often increased in children with histories of adversity or developmental disorders, who are over-represented in children and adolescents identifying as trans.

An ideological distortion of childhood

One of the central ideas of the gender-affirming model of care is that “children know who they are”. This is an ideological assertion that is inconsistent with all existing models of human development. Unquestioning acceptance of adolescents’ feelings about gender fails to consider the prevalence of non-mentalizing thinking in children and young people. This claim is fundamentally at odds with the scientific basis and the clinical ethos of child psychiatry. However, it was unfortunately not disputed by child psychiatrists either in the clinical workplace or the public sphere.

Mainstream child psychiatry draws on established theoretical models of parenting children such as Circle of Security and behavioural models like Triple P. These models focus on parents achieving a balance between appropriate, firm boundaries while maintaining emotional connection. There are no accepted or evidence-based parenting frameworks that support extensive parental accommodation to children’s expressed desires. By extension, endorsing permanent medical interventions in response to adolescent distress is not based on developmental thinking or clinical logic.

The claim that gender interventions reduce suicide risk is false. This assertion was never challenged or debated by the profession as a whole. Why child psychiatry failed to appraise the research literature to identify the lack of evidence underpinning this claim is an important question. This is particularly perplexing given that there are no suicide risk management frameworks within child psychiatry that involve parents or clinicians acquiescing to an adolescent’s extreme demands. Acquiescence is understood to risk positively reinforcing escalations, thereby contributing to future risk by engendering an unhealthy behavioural pattern. Accepted frameworks for managing acute suicide risk within child psychiatry instead focus upon creating a risk management (safety) plan, with short-term inpatient containment or intensive outpatient contact where required. Longer-term management entails therapeutic interventions to increase distress tolerance, and which support the maintenance of activity and roles to “build a life worth living”.

Child psychiatrists as experts

Child psychiatrists lead clinical teams within child and adolescent health services. In private practice, they are often the highest escalation point before a tertiary service referral. Child psychiatrists have the authority of being medical doctors specialising in the management of mental illness. Child psychiatry’s expertise extends to knowledge of normal development, family functioning and patterns of psychological disturbance.

Parents of young people with gender dysphoria are often frightened and confused and they consult child psychiatrists because of their expertise. Using their expertise in the areas of child development, parenting and suicide risk management, child psychiatrists were ideally placed to challenge the gender movement’s unscientific assertions, including its idiosyncratic conceptualisations of adolescence and its recommendations for how to manage distress. The vast majority failed to do so.

Failure of authority

The affirmation of an adolescent’s claimed gender identity through medical or surgical interventions represents the culmination of a series of failures by authority figures to protect the adolescent.

The protective role of teachers was undermined by Human Rights Commissions producing documents indicating that failure to socially affirm a child at school may represent discrimination. Schools also deferred to paediatric gender clinics which recommend affirmation on health grounds.

The normal protective instincts of parents were overcome by the provision of a false narrative by the medical establishment, that affirmation reduces suicide risk and has positive benefits to mental health. Furthermore, the interventions were claimed to be “safe and reversible” with low rates of regret.

Several factors contributed to the failure of child psychiatrists working outside of gender clinics to raise concerns. Failure in the chain of trust in medicine has been documented. Doctors rely on specialist colleagues to be experts in their field, not activists. In addition, health services mandated an affirmation approach, and government conversion therapy legislation forced private practitioners in some Australian states to affirm. Aware of medicolegal risks, child psychiatrists referred patients to gender clinics to avoid the legal and professional consequences of either affirming or not affirming children with gender distress.

Initially, accurate scientific knowledge regarding gender interventions was difficult to access. Internationally, activist gender clinicians were prolific in the production of poor-quality research claiming benefits from gender interventions. The peer review process of scientific journals repeatedly failed to expose such false claims of benefit, ultimately failing their readership and the patients they treated. The abstract often claimed certainty of benefit while the body of the study, hidden behind a paywall, painted a very different picture. Subsequent articles often cited the untrue claims made in previous studies. As noted by the Cass Review, influential worldwide affirming guidelines were subject to circular referencing. Most child psychiatrists were ill-equipped or unwilling to deal with such determined scientific misrepresentation.

Consequently, understanding the lack of evidence underpinning gender interventions was initially not straightforward for those child psychiatrists working outside of gender clinics. Subsequent widely publicised international events—such as the release in April 2024 of the UK’s four-year investigation into NHS gender paediatric services involving systematic reviews of the global research literature—revealed a lack of evidence underpinning gender interventions. Yet this still failed to mobilise child psychiatrists to speak out against gender interventions.

Furthermore, both internationally and locally, a small group of child psychiatrists remained directly involved in transitioning children despite the repeated findings of systematic reviews that the evidence of benefit was weak while the harms were known. This appears to suggest that some members of child psychiatry bodies, including the Faculty of Child Psychiatry within the Royal Australian and New Zealand College of Psychiatrists (RANZCP), are driven by ideology rather than science. We have previously speculated about the psychodynamic factors at play in gender clinicians.

As a representative body for its members, the failure of the RANZCP leadership to call for a halt to gender interventions for minors and vulnerable young adults may be related to professional self-interest and advancement. Key individuals may be aligning themselves with governmental agendas. Alternatively, it is possible that some college board members may have ideological, personal or financial interests in continuing gender interventions.

The plight of detransitioners

Understanding failures in the chain of authority tasked with protecting adolescents is likely cold comfort for detransitioners.

Because interpersonal interactions are so important, detransitioners may blame immediate authority figures, such as affirming parents, teachers and health providers, rather than faceless government and health service bureaucrats and medical college representatives who arguably carry the greatest liability. Detransitioners often reflect on the vulnerability of their adolescent self and carry feelings of betrayal and personal hurt. They struggle with the reality that the people with whom they engaged misunderstood their distress and encouraged them along a harmful pathway.

Parents on the frontlines are likely to be blamed when the responsibility actually lies in the entire chain of protective failures. However, a detransitioner’s need for an ongoing relationship with their parents may shield them from their anger to a certain extent. In order to give detransitioners the best chance of maintaining family relationships, it is crucial that the field of child psychiatry publicly acknowledges its high level of culpability for the harms it has caused. This will inevitably affect the capacity of those who have been harmed to trust the medical profession, due to feelings of anger, scepticism, and uncertainty. Nevertheless, it is arguably an ethical imperative that members of the profession own up to their responsibility for harms, rather than allowing parents to be scapegoated.

What the RANZCP should do

Establish specialist health services for detransitioners

Detransitioners may be reluctant to engage with the health services that were responsible for their transition. They may also fear engaging with unsympathetic health professionals. Detransitioners may derive the most comfort from sharing their distressing experiences with other detransitioners. Alternatively, they may attempt to self-manage through wellness activities. Some may struggle to recover and suffer prolonged distress resulting in ongoing maladaptive coping strategies and impairment in their functioning and quality of relationships. Due to the extent of this suffering, some may not be able to avoid engaging with mental health services.

Therefore, the RANZCP needs to call for, and assist in commissioning, detransitioner support services involving sympathetic psychiatrists, general practitioners and endocrinologists. Multi-specialist care is required to address the extensive physical, hormonal and psychological issues affecting the cohort, in addition to providing assistance for any psychosocial rehabilitation needs.

A statutory compensation scheme

It is unreasonable to expect victims of gender-affirming medical harm to suffer the stress and public exposure involved in taking legal action to seek compensation for physical and psychological damage inflicted upon them by health professionals. The RANZCP should call for the establishment of a statutory compensation scheme to allow a quick and private process for redress.

Remedial training

Members of the college’s Faculty of Child Psychiatry should be required to undergo a remedial training program with content related to the lack of evidence underpinning gender interventions for minors, the concepts of evidence-based medicine including scientific paper appraisal, the developmental stages of childhood and adolescence, and an ethics module focused on situations with competing ethical values. The ethics module should apprise members of the fact that, whilst the principle of autonomy in medicine establishes the moral and legal right of competent patients to refuse any medical intervention, there is no corollary right to receive interventions that are not beneficial. Respect for patient autonomy does not negate clinicians’ professional and ethical obligation to protect and promote their patients’ health.

Truth-telling sessions

The RANZCP should hold truth-telling sessions to allow detransitioners the opportunity to privately share their experiences with senior representatives of the college. This may allow the development of a collection of testimonies, a living document, as a resource for academics, researchers and psychiatrists contemplating this shameful chapter in the history of child psychiatry.

A statement of culpability and apology

The RANZCP should promptly issue a statement of culpability and apology. Previous apology statements by the RANZCP have come decades after events of concern. We urge the college to acknowledge culpability for this profound health care failure in a timely manner. The statement should recognise the failure of the college to support any formal enquiry into the issue and its failure to call for the cessation of puberty blockers and cross-sex hormone prescription.

The following suggested apology is in line with previous RANZCP statements.

The Royal Australian and New Zealand College of Psychiatrists apologises to those harmed and to the Australian and New Zealand public for the participation of our profession in providing harmful gender-affirmation practices to minors and young adults.

From 2012 onwards, paediatric gender clinics were set up by state health services in Australia. Care in these clinics was provided according to the affirmation model outlined in the Royal Children’s Hospital Melbourne guideline which was subsequently discredited. Child psychiatrists primarily oversaw clinical governance within gender clinics.

Gender-affirming interventions included social, medical and surgical transition. In accordance with the affirmation model, children were affirmed in their claimed gender identity from early childhood and encouraged to socially transition. Children as young as nine were prescribed GnRH agonists.¹ Those as young as 14 were prescribed cross-sex hormones.

Identified harms from these interventions include infertility, impaired sexual function, long-term physical health problems and permanent disfigurement, as well as regret. The model was likely iatrogenic², being detrimental to the prospect of natural recovery from gender distress during adolescence. Parents were cajoled into consenting to gender interventions for their children by being told that such interventions reduced suicide risk and were “safe and reversible”.

Psychiatrists have professional and ethical obligations to ensure that mental health interventions for patients are safe and evidence based. This is particularly important when the proposed interventions carry serious risks that were not previously associated with mental health interventions for physically normal children. This should have raised alarm within the profession.

The consequences of the profession’s failure to halt gender interventions for minors and vulnerable young adults have been catastrophic for individuals and the community alike. We acknowledge the suffering of parents and families of children experiencing gender distress, whose ability to protect their child from harm was undermined by the failures of our discipline. We also acknowledge the RANZCP’s failure to call for an inquiry into these interventions, or to cease their prescription once the lack of evidence of benefit and the harms came to light.

Sadly, the RANZCP expects to see an increasing number of medically harmed detransitioners who will require specialist support services for their physical, endocrine and mental health needs. The RANZCP recognises the need for appropriate restitution or compensation for those harmed. It is unreasonable to expect victims to endure the prolonged hardship, financial risk and public scrutiny involved in seeking redress individually through the courts.

As a profession, we owe it to those affected to address this issue head on. The RANZCP will conduct an investigation into our organisation’s and our members’ failures to raise concerns sufficiently. We will ensure that our members undertake remedial education on evidence-based medicine, medical ethics and child development.

The RANZCP offers its deepest apologies to those affected, their families and whānau³, and all impacted by gender-affirming interventions.

This is a shameful chapter in our profession’s history.

We failed you.

We recognise our part in this, acknowledging that it was our actions and inactions that allowed these harmful practices to continue unchallenged.

We broke your trust.

From here on, we are committed to providing the best mental healthcare, guided by evidence and expertise.

This apology cannot change the past. It is intended to convey our acknowledgement of the mistakes made and their impact on so many people.

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Dr Jillian Spencer is a child and adolescent psychiatrist. Dr Roberto D’Angelo is a psychiatrist and psychoanalyst. Dr Patrick Clarke is a psychiatrist. A copy of their article with full references is available on request. Email: genderclinics@gmail.com

GCN does not dispute that gender-affirming clinicians believe their interventions help vulnerable youth.

1. Drugs used off-label to block the natural sexual development of a child.

2. Illness caused by medical treatment.

3. A New Zealand Māori word for extended family.