Truth cuts deep

The language games of gender medicine obscure a troubling reality

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The candidate was right; she knew she was right. The prime minister said she had a right to express her concerns, but then he crumpled. The political journalists who challenged him were wrong. No doubt they still think they’re on the right side of history. They suffered no penalty; the record hasn’t been corrected. And it just goes to show, in microcosm, the derangement of gender medicine as a public policy debate.

All this played out at a heated media conference in Sydney on 10 May 2022, less than a fortnight before Australia’s federal election.

It was “the death of shame”, according to one media write-up. The centre-right Liberal Party prime minister Scott Morrison had pushed a moral panic dangerous for a vulnerable community—a panic with no factual basis. At least, that was the story that stuck.

On live TV, a journalist at the campaign trail media conference lectured Mr Morrison that, according to a source from his own government, the transgender surgery he claimed to be troubled about simply “can’t happen to minors in Australia.” The prime minister hesitated and hedged his remarks; political commentators seized on his apparent error as the day unfolded.

On ABC TV, the public broadcaster with a $1 billion-plus budget and nationwide reach, presenter Joe O’Brien interviewed journalist Patricia Karvelas, a rising star of the network. “Facts” was the word she hammered, again and again.

“Before you’re 18, Joe, there’s no surgery at all, for anyone under 18, there’s nothing like that,” Ms Karvelas said. “I feel like we’ve lost the facts in this conversation, we are having a very toxic conversation which is incredibly hurtful to a tiny minority of [trans young] people who are going through something incredibly difficult.

“And we are also getting basic facts wrong, if you’re under 18, you don’t have surgery, people should get across the facts here. I am across these facts, it’s a community [of trans people] I have quite a lot to do with…”

Ms Karvelas said the debate urged by the prime minister was “just a conversation, as far as I can see, about nothing. The thing that happens to [trans] people under 18… there are puberty blocking drugs [for children in distress] … what often the medical community does at that point is to put off puberty¹, to actually buy time.”

In fact, all three stages of the so-called Dutch protocol of gender medicalisation have been (and still are) available for minors in Australia—puberty blockers, synthetic cross-sex hormones and surgery. Family Court cases making it easier to get these medical interventions have been reported as good news by the ABC and celebrated by human rights lobbies.

Ms Karvelas and her political journalist tribe got it wrong. It didn’t stop her being chosen to present an ABC TV Four Corners investigation into the only major children’s hospital in Australia cautious about gender medicalisation. The July 2023 TV program amplified the dogma that any approach other than the “gender-affirming” treatment model is likely to do harm. At the heart of the program was 14-year-old Noah, a female who identified as a boy and had expressed interest in puberty blockers. Tragically, the life of Noah ended in suicide.

With the fleeting caveat that “we can’t know”, Four Corners gave viewers the impression that Noah’s lack of access to “specialist gender support” was the reason for suicide. However, senior staff of the Children’s Hospital at Westmead in Sydney had formed the opinion that Noah’s eating disorder—a condition with its own suicide risk—should be the “primary focus” of treatment. Four Corners told viewers nothing about the danger of “diagnostic overshadowing”—when a gender fixation obscures other underlying problems in need of attention. This has been a key concern raised by paediatrician Hilary Cass in her independent review of the London-based Tavistock gender clinic.

But back to the Morrison-Karvelas story, which began with another teenage girl.

This girl’s image appeared in a November 2021 Twitter thread posted by Sydney lawyer Katherine Deves², mother of three daughters and a campaigner for women and girls against gender ideology.

The image of this teenager—her face blurred and masked, her chest bare—shows bruising and scarring after a double mastectomy. Such images populate social media, often with celebratory tags such as “top surgery” or “trans euphoria.” For Ms Deves, it was a disturbing image. She tweeted that, “[People] will not stand for seeing vulnerable children surgically mutilated and sterilised in furtherance of an unattainable idea. The lawsuits will be legion, as will the government inquiries.”

Her warning was not directed at any one country; this is happening across the developed world. The teenager in the image was probably American.

Ms Deves went on to be preselected as a Liberal Party candidate for Australia’s May 2022 federal election. She was reportedly hand-picked by Mr Morrison.

When her mastectomy Tweet resurfaced in the media the month before Australians went to the polls, it didn’t lead to a debate about the wisdom of trans medicalisation or the potential harm to distressed children.

It’s true the ensuing story was one of revulsion—but it was directed at Ms Deves for using the words “mutilated and sterilised”, not at the practice of mastectomies or the use of hormonal drugs expected to sterilise minors, many of them likely to be mentally unwell, autistic, same-sex attracted or traumatised.

This troubling reality was ignored by journalists as they pursued a conservative political candidate who could be portrayed as, at least, insensitive to a suicide-prone minority. Ms Deves and her family were besieged with threats and at one point had to go into hiding.

The story took a disorienting turn at Mr Morrison’s 10 May 2022 media conference where the prime minister distanced himself from the language³ used by Ms Deves but supported her concerns. Encircled by journalists reporting his election campaign, Mr Morrison said—

“What we’re talking about here is gender-reversal surgery for young adolescents. And we can’t pretend this is not a very significant, serious issue. It’s complicated. And the issues that have to be considered, first and foremost, [are] the welfare of the adolescent child—and their parents… [It’s not] a minor procedure—this is a very significant change to a young person’s life, and it is often irreversible.

“Ensuring that we understand what we’re dealing with here is incredibly important. And that’s why our government, and also state governments, are so focused on ensuring that we get the right supports—counselling, psychiatric supports, but ultimately the supports for the parents and the family to make the best possible decision. Now I, [and] I’m sure, many other Australians are concerned. This is a concerning issue, it’s a troubling issue.”

And then a young female journalist interjected, telling the prime minister that under-18s could not undergo “gender-reassignment surgery […] according to your own Healthdirect.gov.au website… it can’t happen to minors.” The prime minister blinked; he appeared to concede the point. The headline in Guardian Australia was, “Morrison stands by Katherine Deves and wrongly claims ‘young adolescents’ can have gender-confirmation surgery.” The article cited Healthdirect.

If you search that website now—its slogan is “Free Australian health advice you can count on”—you will not find the trans surgery term that appeared when those political journalists went Googling in May 2022. We’ll come back to this website and its stealth edits.

For now, let’s list some of the procedures that are lawfully available to minors in Australia—

“Double mastectomy; phalloplasty (creation of a pseudo-penis); hysterectomy; bilateral salpingectomy (removal of the fallopian tubes); and vaginoplasty (creation of a pseudo-vagina).”

This is not an exhaustive list⁴. It comes from the 2018 re Matthew case, in which a single judge, Judith Rees, made the momentous decision to cut back the Family Court’s supervision of surgery for minors with gender dysphoria. Until that ruling is challenged and set aside, it is no longer necessary to make an application to the court before this surgery, unless there is disagreement between parents or doctors about, for example, the capacity of the child to give informed consent.

It’s federal family law, not some website with “gov.au” in its name, that determines access for dysphoric minors to the treatments of the three-stage⁵ Dutch protocol. The ruling by Justice Rees applies to “Stage 3 treatment”, meaning any trans surgery, notwithstanding the fact that the patient in the case known as “Matthew”, a 16-year-old female, wanted mastectomy, not hysterectomy.

So, Ms Deves and Mr Morrison were right, and the political journos were wrong.

Some of the media coverage stated that surgery was not available at all to minors; some quoted trans activists who cried misinformation and claimed surgery was only rarely available after exhaustive assessment. No evidence for this claim was given.

Journalists, by now, should be familiar with trans activist tactics. “Sex-change surgery for children” is never going to be popular. When there is unwanted scrutiny of the gender medicalisation of minors, activists seek to minimise its extent and cloud its physical realities. This tactic relies on ill-informed, uncritical or biased media coverage.

Journalists—and the prime minister—appeared to assume back in April-May 2022 that when Ms Deves had objected to children being “surgically mutilated and sterilised”, she was referring to genital surgery known until recently as “sex-reassignment surgery”.

Although this surgery is lawfully available to minors in Australia, it is so radical it seems unlikely that any reputable surgeon here would agree to do it. But there is no good public data to show that an expression of concern about Stage 3 treatment—genital surgery or mastectomy—is “a conversation about nothing.” Its lawful availability, plus the self-radicalising tendency of the gender-affirming treatment approach, are enough to make it a live ethical issue.

Or do activists seriously contend that the wisdom of surgically removing the healthy breasts or wombs of distressed teenage girls cannot be debated until we cross some threshold of case numbers?

Nothing about the Deves Tweet confines it to Australia. In the US, an analysis of Komodo health insurance claims found 56 cases of genital surgery among patients aged 13-17 with a prior diagnosis of gender dysphoria from 2019-2021. Over the same period and for the same age group, the analysis found 776 trans mastectomies. Both totals are likely to be underestimates. American trans activists—many of them social justice warriors, not themselves trans-identified—routinely claim that under-18 surgery simply does not happen. Gender dysphoria diagnoses, puberty blockers, cross-sex hormones and surgery—all have been on the rise among minors in the US. Where the US goes, Australia often follows.

The more obvious reading of the Deves Tweet is that she was targeting trans mastectomy—hence the image of the scarred teenager—and the sterilisation likely when a child is given hormone suppression early in puberty followed by cross-sex-hormones. Children’s hospital gender clinics in Australia are certainly giving minors hormonal interventions that may sterilise them, and our court records confirm that surgeons are performing trans mastectomies on patients under 18. The extent of this medicalisation is not clear; only patchy data is available and that in itself ought to be a red flag. Our political journalists have displayed little knowledge or curiosity about this.

If taken seriously, the activist gambit of playing down the gender medicalisation of children would be a confession of failure because these treatments are supposed to be “lifesaving”. And sure enough, in less visible policy contexts where rules are being remade, the approach of gender clinicians and activist lobbies is very different: they stress the centrality of medical treatment for minors and seek to wind back checks and safeguards as unnecessary and discriminatory “gatekeeping”.

In the re Matthew case, an anonymous paediatrician highlighted expert opinion⁶ that “for many transgender individuals surgery is essential and medically necessary to alleviate their gender dysphoria.”

At a 2019 royal commission into mental health, Australia’s most influential gender-affirming clinician, Michelle Telfer, testified that “many” of her recent trans-identifying female patients wanted “chest reconstructive surgery.” She said this surgery—a double mastectomy—was “an integral part of the transition process for trans males.” To bolster her case, she cited a 2018 US study in which 33 minors underwent trans mastectomy; seven were younger than 16. Dr Telfer wanted an injection of funds so that the Royal Children’s Hospital Melbourne (RCH)—home to her gender clinic—could carry out these operations.

The 2018 treatment guideline issued by RCH—and used by other children’s hospitals around Australia—states that “chest reconstructive surgery is regularly performed across the world in countries where the age of majority for medical procedures is 16 years.” The guideline advises that psychosis or depression in a child is no necessary obstacle to medical transition. In a 2019 protocol for the Trans20 longitudinal study at RCH, the authors stated that “genital surgery is generally only advised after the age of majority”, but did not explain the criteria for exceptions.

RCH recently referred a 15-year-old female patient to a private surgeon for mastectomy, according to posts in a support group for parents of “trans children”. The hospital reportedly referred another 15-year-old patient interstate for mastectomy in 2020. RCH usually ignores my requests for comment or clarification but in November 2021, it did issue a statement saying it was “not aware” of any gender clinic patients being referred to private surgeons. At the time, I was reporting a journal article by Melbourne psychiatrist Alison Clayton in which she argued there was so little evidence for mastectomy as a treatment for gender dysphoria in minors that it should be regarded as experimental. She suggested it might go down in history as “dangerous medicine” comparable to lobotomies.

Sounds like a conversation to me. As far back as 2016, professor of paediatrics John Whitehall of Western Sydney University reported in Quadrant magazine cited the case of a minor approved for trans mastectomy by Australia’s Family Court. “Quinn”, a 15-year-old female who identified as a boy and was being medicated for depression, had declared, “I don’t belong in this body like it is”. Her mother said that “Quinn has researched top surgery and is following top surgery journeys of other transgender men on Facebook.” The court decided the child was competent to consent to surgery. In a 2020 article, Professor Whitehall said he had identified in Family Court records a total of five cases of mastectomy for minors with gender dysphoria. I asked the court a few years ago for a list of gender dysphoria cases and their outcomes but was told this was too onerous a task.

In any event, the fact of under-18 trans mastectomy—and the wish of gender clinicians to expand its use—was a running theme in my 2019-21 gender clinic coverage for The Australian newspaper. How could anyone claiming to be informed about gender medicine assert that under-18 surgery simply did not happen in Australia?

One reason may be that gender medicine is played as a language game in which those cast as “progressive” and “kind” are supposed to signal moral approval for invasive treatment while the terminology keeps changing.

It is an ever-shifting answer to a difficult question—

How can we describe hormonal and surgical interventions in a way that does not pathologise gender-diverse identities, and yet promotes these treatments as both medically necessary and human rights, such that treatment should be given to children who say they want it from the onset of puberty?

The language game is also a public relations exercise. Maybe “gender-affirming surgery” for minors will generate less pushback because the knife merely affirms an “always-was” gender identity, as opposed to the claim of radical, indeed magical transformation wrought by a “sex change” or “sex reassignment”.

The medical procedures—with their risks, poor evidence base and dubiously informed consent—remain the same, but not many journalists go beyond the latest genderspeak to dig into the reality of bodies with puberty on hold, bodies injected with wrong-sex hormone drugs, and bodies turned into a surgical facsimile of a wish.

Like the media pack of 2022, I consulted Healthdirect, the website that had supposedly wrong-footed a prime minister.

I found it now refers to “gender-affirming surgery”—and no longer the “gender-confirmation surgery” reported during the 2022 election campaign. Same surgery, same language game.

Also, back then, according to an archive saved on 27 March 2022, the website attributed the supposed minimum age of 18 for gender-confirmation surgery to international guidelines which would not override the more permissive stance of Australian family law.

Today’s Healthdirect webpage does try to explain some of the change in terminology—

“Bottom surgery is called ‘genital-reconfiguration surgery’. This was previously known as ‘sex-reassignment surgery’ or ‘gender-confirmation surgery’. The name change shows that your genitals don’t define your sex or gender.”

“Gender-affirming surgery” is up-to-date activist usage to refer to top and bottom surgery.

At the time of writing, the Healthdirect webpage states that to get gender-affirming surgery, you must “be over the age of 16 for top surgery, or 18 for bottom surgery.” The source of this claim is not given; there is no reference to Australia’s family law, which makes no such age distinction.

The earliest archive I could find for the webpage is from April 2019.

In two short sentences, it makes two starkly pseudoscientific claims—“Gender-confirmation surgery (formerly called gender-reassignment surgery) transfers people with gender dysphoria to their desired biological sex. It is also possible to change one’s sex by taking hormones [Emphasis added].”

By April 2021, these claims had vanished, replaced by the formula that gender-confirmation surgery “allows people with gender dysphoria to permanently alter their body parts associated with their biological sex. It is also possible to change your physical appearance by taking hormones.”

In the intervening two years, science did not suddenly undiscover the miracle of sex changes. Was this just another opaque update in the gender language game? Why should anyone trust this website? Where does its evanescent content come from?

Trans activist groups are prominent among the sources cited and recommended by Healthdirect. The surgery webpage’s current top pick for more information is the radical TransHub⁷ website.

Healthdirect lists a host of “information partners” who provide “quality, trusted content” for its pages—including ACON, the former gay rights organisation which is now a de facto trans activist lobby and is responsible for TransHub. Then again, many other institutions across society are uncritical sources of affirmation-only doctrine.

The home page of Healthdirect Australia, a public company, sports the logos of its shareholders—the federal, state and territory governments to which, it says, it is “directly accountable”.

So, would Australia’s actual health officials insist that government-ish information be less susceptible to pseudoscience and activist identity medicine?

Probably not. In November 2022, Australia’s Assistant Minister for Health and Aged Care, Ged Kearney, a former nurse, was briefed by her department for a Parliament House promotion of the documentary film The Dreamlife of Georgie Stone, which tells the story of a trans campaigner who, more than a decade ago, was the youngest patient to be given puberty blockers at Dr Telfer’s Melbourne gender clinic.

The brief for the assistant minister—obtained under Freedom of Information law—runs to nine pages, reads like a trans lobby script and assumes that the key debate about gender-affirming care is how to expand access to medicalisation, rather than any need to interrogate its evidence base and safety.

The foreshadowed closure of England’s Tavistock clinic does get a mention, but only to warn Ms Kearney that it is causing “distress to the trans and gender-diverse community” in Australia. Why? Because, the health officials explained, news of the Tavistock’s downfall had led to increased concern about gender medicine in Australia and renewed calls for a national inquiry.

The briefing note also advises Ms Kearney—“Do not use the term ‘surgery’ without including ‘gender-affirming surgery’.”

Little of this would surprise Katherine Deves.

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GCN does not dispute that advocates for the gender-affirming treatment approach believe it benefits vulnerable youth. A spokesman for Healthdirect Australia said its webpage content was “informed by current, evidence-based sources” and checked before publication. GCN asked Ms Karvelas if she had corrected her statements from 2022

1. On ABC radio last month, Ms Karvelas interviewed Hannah Barnes, the British investigative journalist who helped expose the shortcomings of the Tavistock clinic. The occasion was the decision by England’s NHS to restrict puberty blockers to a possible clinical trial. Ms Barnes said such a trial, if it obtained ethics clearance, was not expected to start before the end of the year. Ms Karvelas suggested it was “quite controversial” if there were to be no access to puberty blockers pending a trial that might not happen. Ms Barnes: “Is it controversial or is it just, that’s evidence-based medicine?—and I think that’s what’s been lacking in this area for a long time.” Ms Barnes pointed out that the lack of “a decent evidence base” for puberty blockers had been known—and ignored—for many years, to the cost of distressed young people. She cited England’s 2020 systematic review of the evidence, the gold standard for testing the robustness of data underpinning a treatment. This point seemed lost on Ms Karvelas, who protested: “Many of those who have been on puberty blockers—not all—will tell you it was lifesaving, others have clearly regretted the decision.” What are the chances of ABC audiences being offered a proper explanation of the role of systematic evidence reviews in the post-2019 European shift to caution on gender medicine? These reviews—undertaken independently in Finland, Sweden and England—show the evidence base for hormonal treatment of dysphoric minors to be very weak and uncertain; children have been given experimental medicine without proper safeguards.

2. Ms Deves was a contact of mine when I was reporting the implications of self-declared gender identity for female sport for The Australian newspaper.

3. Some detransitioners have referred to their own post-mastectomy bodies as mutilated; others reject the term as unhelpful, given that they have to learn to live with irreversible changes. Grieving parents sometimes use the term; its use by others divides opinion. As for trans activists, they routinely resort to hyperbole.

4. In the current “standards of care” (SOC-8) from the World Professional Association for Transgender Health (WPATH), the category of gender-affirming surgery (or Stage 3 surgery in Australian family law) has been extended to cover a “eunuch” identity. SOC-8 says: “As with other gender-diverse individuals, eunuchs may also seek castration to better align their bodies with their gender identity. As such, eunuch individuals are gender non-conforming individuals who have needs requiring medically necessary gender-affirming care.” In what appeared to be a legally defensive manoeuvre WPATH abruptly abandoned minimum ages for trans surgeries—apart from phalloplasty—after initial publication of SOC-8. Trans surgery used to have a binary logic (male to female or female to male) but how do we explain the wish of “non-binary” females for mastectomy? In North America, gender-diverse “embodiment goals” include the creation of a pseudo vagina for a male who retains his penis.

5. The idea of three distinct stages is increasingly questioned. Data suggests that the vast majority of children started on puberty blockers will proceed to cross-sex hormones, meant to be taken lifelong. Detransitioners have spoken of feeling pressure to progress from hormones to surgery. In this sense, very young children are put on a one-way treatment path with profound implications for their future reproductive rights and sexual function.

6. The experts were WPATH, a hybrid clinician-activist lobby which allows members with no medical qualifications to exert influence over its standards of care. Leaked internal files confirm the view that WPATH is not like any mainstream medical body. Australia’s children’s hospitals still invoke WPATH as if this guarantees the quality and safety of treatments offered by their gender clinics.

7. TransHub used to advise 16- and 17-year-olds that they could take advantage of the fast-track “informed consent” model to get irreversible cross-sex hormones from primary care doctors without mandatory mental health screening or checks that both parents approved. The website had to be corrected by ACON after a judicial rebuke in the 2020 Family Court case of re Imogen.