Witch hunt

Clinicians who point out the flaws and dangers of 'gender-affirming care' are hounded and harried

Photo by Bee Felten-Leidel on Unsplash

The purge

The persecution of health professionals who uphold their ethical responsibilities by questioning “gender-affirming care” is unprecedented. The aim of unceasing official complaints is to silence the person, and if that fails, destroy their careers. No evidence-based response to the complaint is acknowledged; the demand is total capitulation. There is no evidence of any similar organised purge of health services in modern times. The words that come to mind are “witch hunt”.

It began with Canadian psychologist Dr Kenneth Zucker, who in 2015 lost his job as the head of a Toronto-based gender identity clinic after false charges of conversion therapy because he used a cautious approach—akin to “watchful waiting”—with gender-questioning young people. Tellingly, it was later found that the complaint against him was based on a lie.

The attacks on health professionals who challenge the use of the gender-affirming model with children and adolescents have continued unabated ever since. In Australia, psychologist Professor Dianna Kenny was one of the first to actively challenge this model, which has led to six complaints against her, from the NSW Health Care Complaints Commission, the Australian Health Practitioner Regulatory Agency, and the ACT Human Rights Commission. Each time she has been able to defend herself and the result was the provision of “advice and no further action,” or the case was discontinued after a council process. The ACT human rights case is still pending; the process is the punishment. Unbowed, she has recently published the book Gender Ideology, Social Contagion and the Making of a Transgender Generation.

Even stating that the fundamental responsibility of every health professional is to conduct a comprehensive assessment to ensure the correct diagnosis is, apparently, transphobic, as I found out when a complaint was made against me to my professional society.

The complainants alleged that I was not practising the “client-led” approach of affirming a person of any age—including a child or adolescent—who says they are trans, and therefore my practice was “unsafe” for these clients. Gender-affirming clinicians seek to sidestep the need for proper assessment by claiming that any co-morbid mental health problems are most likely due to “minority stress”—a reflection of discrimination and social stigma. Trans ideologists insist that health professionals should not be “gatekeepers”, and that even young children should be given any treatment they request.

Exemplary punishment

A current case is that of Dr Jillian Spencer, a child psychiatrist at the public children’s hospital in the Australian state of Queensland. She was stood down in 2023 for expressing concerns about the unquestioning approach to gender dysphoria treatment. She said out loud what many other practitioners think: that children experiencing gender confusion deserve thorough psychological assessments rather than immediate medical interventions.

In particular, she did not want to use the preferred pronouns of children because she believed this started the young person on the affirmation pathway of social transition, followed by puberty blockers, cross-sex hormones and gender surgeries. In her view, it is a substandard level of care to assume from the outset that a child is the opposite sex and to fail to explore the gender distress itself.

Dr Spencer is up against trans advocates who have played a very long game to be in a powerful position to dictate health policy. Arising out of the emerging Queer Theory of the 1990s, a global network of trans activist groups under the name InterPride began to offer workshops and lectures to private and government organisations across the world. Employers pay to participate in a rating of their organisation or service on a “workplace equality index”. The resulting ranking is then used by employers to promote their institutions as “inclusive”.

The most far-reaching initiative was to require employers to guarantee the hiring of trans people or trans allies to key positions in management, giving them influence over policies that might advance the trans activist cause.

Under the internationally imitated workplace equality scheme of Stonewall, the UK LGBTQ lobby, participating employers had to—

“Have at least one diversity/HR professional whose job description, performance appraisal or work plan includes specific and detailed LGBTQ inclusion objectives/targets

“Have an executive sponsor located with documented role expectations [and] accountabilities related to LGBTQ inclusion work and advocacy within the organisation

“Include specific diversity and inclusion accountabilities, job goals or expected outcomes within senior management appraisals beyond generic company values addressing diversity/inclusion

“Establish and promote an internal LGBTQ advisory group available across the organisation”

In Australia, Stonewall’s model was adopted by the former gay rights organisation ACON with its Pride in Diversity program. Like other states, Queensland has public institutions heavily influenced by gender identity ideology. Its “public sector LGBTIQ+ steering committee” lists Pride in Diversity as a “partner”. The government’s own Pride in our Communities Action Plan 2024-26 states an objective for Queensland Health, Dr Spencer’s employer, to—

“Establish an LGBTQIA+ working group including representation from community members and LGBTQIA+ organisations to provide advice and support on the delivery of Queensland Health actions and other Queensland Health LGBTQIA+ policy matters and initiatives.”

This is the kind of ideological capture which entrenches gender-affirming care and shields it from legitimate scrutiny. Dr Spencer is at considerable disadvantage in a David and Goliath battle.

I have had personal contact with several health practitioners on the receiving end of complaints. No alleged infringement is too small: giving negative feedback on an affirmative training workshop; expressing concern about puberty blockers; challenging the belief that a child “knows” they are the other gender/sex; expressing concern that many young people who are being affirmed are likely to grow up gay not trans; discussing the possible role of social influence on trans identity—the list is constantly growing. Those who don’t conform to gender-affirming principles risk being charged with unethical “conversion practices” that are now illegal in many jurisdictions.

Gender-affirming clinicians aren’t a united bunch, with some insisting they do conduct a mental health assessment, but I have yet to see an account of one of these assessments. There are no figures on how often such clinicians offer other treatment options and not mere affirmation. Instead, some signal their position by posting signs in the waiting room which ask the client up front for their preferred pronouns, thus setting the stage for a biased assessment process.

The duty to diagnose, differentially

A differential diagnosis is the process of differentiating between two or more conditions which share similar signs or symptoms. For example, when someone presents with symptoms consistent with generalised anxiety, the clinician must consider whether these symptoms are better accounted for by hyperthyroidism, overuse of caffeine, epilepsy, and so on.

Although differential diagnosis should be an integral part of the assessment of a new client, it is given little weight in the current standards of care issued by the gender-affirming World Professional Association for Transgender Health (WPATH).

Those standards, which run to 260 pages, make only two references to differential diagnosis and these lack detail. One simply states that “susceptibility to social influence impacting gender may be an important differential to consider”. The other says: “Established practice requires the competence to identify and diagnose gender incongruence … and the ability to identify differentials or conditions that may be mistaken as gender incongruence …”

By contrast, the less recent diagnostic manual of American psychiatry, the DSM-5, typically includes differential diagnoses as an essential aspect of the assessment process. In DSM-5, other possible diagnoses for symptoms of gender dysphoria in children are non-conformity to gender roles and autistic preoccupation. For adults and adolescents, alternative diagnoses are given as body dysmorphic disorder; transvestic disorder; and schizophrenia and other psychotic disorders.

In agreement with DSM 5, some clinicians have questioned the assumption that affirming a diagnosis of gender dysphoria is the only correct response to any gender-questioning presentation.

In 2021, a systematic review confirmed that children diagnosed with gender dysphoria often experience a range of psychiatric co-morbidities, with a high prevalence of mood and anxiety disorders, trauma, eating disorders and autism spectrum conditions, suicidality and self-harm. The authors of this review did not support gender-affirming care as the first response to a young person’s distress, instead concluding that mental health issues should be addressed as a priority—

“It is vitally important to consider psychiatric co-morbidities when prioritising and sequencing treatments for children with gender dysphoria (Emphasis added).”

Clinical ideologues

There are three aspects of the gender-affirming model which show it is ideological in nature and not in the best interests of gender-questioning clients.

First, the unethical use of a suicide scare. No competent, ethical health professional would use the threat of suicide to pressure parents into agreeing to their child undergoing social and medical transition, nor use such an emotive claim to garner support in the broader community for the use of gender-affirming care. Not only is there extensive literature on the social contagion effect of repeated reference to suicide in a specific group of people, but the claim that gender-questioning young people have a high incidence of completed suicide is not supported by research.

In the same way, describing every aspect of gender-affirming care as “medically necessary” suggests that clients will suffer in some way if they do not have this treatment. In reality, the term “medically necessary” is used throughout WPATH’s standards of care so that its affirmative interventions will qualify for health insurance cover in the US.

Second, the disrespectful treatment of detransitioners. It is accepted that a 100 per cent success rate for a health treatment is rare, but when a treatment causes harm, it is standard practice that these cases are investigated. Inquiry into adverse events can identify risk factors such that the treatment is not advised for clients with specific characteristics, or an investigation may identify faults in the treatment process.

Puberty blockers, chest binding, cross-sex hormones and surgery have all been found to have adverse outcomes for young clients. While some problems are manageable and the young person continues with transition and others desist from transition with no lasting effects, those who express regret about irreversible changes are dismissed by trans activists as so rare as not to be concerned about.

In fact, the true detransition rate for young people is unknown. The studies cited to support the familiar claim that the rate is less than one per cent are flawed and inapplicable to the group of chiefly female adolescents who have come to dominate gender clinic caseloads over the last 10-15 years. One recent US study of adolescents and young adults found that almost 30 per cent had ceased cross-sex hormones within four years.

Another recent finding was that only 24 per cent of a group of 100 detransitioners had told their former clinicians that they had stopped hormones. Detransitioners are often shunned by their friends and ignored by gender-affirming practitioners, so it isn’t surprising they don’t show up in many studies of treatment regret.

Unfortunately, the extent of adverse outcomes for the current cohort of young people will not be known for some years. Given the success of trans activists in loosening the eligibility criteria for medical interventions, it is probable there will be an increase in poor outcomes. It may take several years for this regret to crystallise.

Advocates for uncritical affirmation prefer to ignore detransitioners because their testimonies of regret undermine the foundation of the affirmative model that if someone says they are trans, they are unequivocally trans and must be affirmed, regardless of co-morbid mental health problems.

Third, the denial of social influence. When Dr Lisa Littman published her paper presenting the idea of rapid-onset gender dysphoria (ROGD) brought on by the influence of peer groups and social media, the backlash was astonishing but logical. The ROGD phenomenon challenges the dogma that a person’s stated belief they are trans arises only because they have an innate sense of their gender that is immutable.

What Dr Littman’s critics ignore is that the possibility of social influence has been acknowledged (albeit fleetingly and belatedly) in WPATH’s latest standards of care, and the power of social influence on young people in particular has been well documented over many years. In my view, ignoring the possibility of social influence is indefensible negligence.

Capture and bias

Trans advocates have been able to radically restrict debate about the reliability and safety of gender-affirming care by their guerrilla warfare against anyone who has the temerity to question this treatment model. Their cries of “no debate” and “the science is settled” are being challenged, but the embedding of trans allies in positions of power in clinical positions, management, and government regulatory agencies such as the Australian Human Rights Commission, means that any clinician who raises concerns has good reason to fear that complaints against them will not be dealt with fairly or objectively.

A major concern of practitioners who question gender affirmation is whether children and adolescents have the capacity for informed consent. These medical and surgical treatments carry the risk of sterilising the young person. Why should this risk of regret be dismissed when it is a significant issue for women who undergo a tubal ligation? It has been reported that between one and 26 per cent of women come to regret this contraceptive procedure. No wonder that medical practitioners are reluctant to perform tubal ligation on young women, single women, and women who have children but are divorced.

When gender-questioning young people are assessed for legal competence to agree to irreversible medical and surgical procedures, how can they possibly grasp the full implications of what they are agreeing to? This is especially problematic if the practitioner is an affirmative advocate promoting these treatments. How exactly do these clinicians explain what is proposed such that the young person agrees?

The evidence base does not favour confident affirmative intervention. Multiple systematic reviews have found the research data for the hormonal treatment of gender-distressed minors to be of low quality and very uncertain.

Consistent with other studies that highlight the flaws in the affirmative model, a 2023 review said—

“The conclusions of the systematic reviews of evidence for [medical transition of] adolescents are consistent with long-term adult studies, which failed to show credible improvements in mental health and suggested a pattern of treatment-associated harms.”

There are, therefore, many good reasons for a concerned health practitioner to challenge the gender-affirming model. Times are changing, and the number of lawsuits will increase, but how many vulnerable young people will be harmed in the meantime?

The case for humility

Clinical work is challenging. One of the professors in my postgraduate clinical training course stressed that humans are complex creatures with much still to be understood, so any clinician will—not may—sometimes come to the wrong conclusion. Keeping that in mind is humbling but hopefully lessens any errors of opinion and helps the clinician be more reflective about their work. A clinician who is convinced they are always right is at best problematic, at worst dangerous.

The professor advised that each client be treated as an individual study, emphasising the importance of a differential diagnosis. This concept is so fundamental to good care that I made “n=1” the logo for my letterhead as a clinical psychologist. No treatment should begin until all possible options have been eliminated. It is not good practice to use a person’s preferred pronouns before a diagnosis of gender dysphoria is confirmed.

The concerns of practitioners who challenge gender-affirming care have nothing to do with “anti-trans” prejudice. These are professionals serving the public interest by critiquing a treatment model that not only shuts down any opposition but seeks to punish anyone who expresses concern about some or all aspects of the approach. For client safety, no theory or recommended treatment can ever be beyond scrutiny.

Gender-affirming care is an ideologically driven theory translated into practice by health professionals who have a particular view about sex and gender identity. It is unacceptable to have this ideology entrenched in health services by employees in positions of influence. For integrity, health services must abandon any relationship with Pride organisations or other ideological lobbies. And there must be an end to manufactured complaints against health practitioners who are doing the right thing by challenging an unchecked treatment model that risks harm to vulnerable young people.

Dr Sandra Pertot retired not long ago after 50 years of practice as a clinical psychologist specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity