Trans activism is holding proper health care to ransom

The explosive growth in gender-questioning patients and gender-affirming services in Australia needs to be addressed similarly to England, following its Cass Review.

The Cass Review of gender medicine in England, released this week, captures a medical establishment waking up to a major scandal.

Thousands of transgender and gender-questioning English children have been exposed to harmful interventions under the medical treatment model called “gender-affirming care”.

This failure was caused by medical authorities who abandoned traditional safeguards in the face of pressure from international trans activist groups. Many other countries are now starting to acknowledge similar failures, led by Sweden and Finland.

Gender confusion is a normal part of adolescence that is likely to resolve without treatment in the overwhelming majority of cases. The gender-affirming care described in the review trapped gender-confused kids on a treadmill from which few escaped, leading from social transition, through puberty blockers, to hormone treatment and surgery in many cases.

As widely publicised when puberty blockers were banned in England a few weeks ago, these treatments have significant side-effects, including fractured bones, infertility and severe sexual dysfunction, which can be lifelong.

Cass makes it impossible for Australian authorities to continue to ignore warnings that Aussie kids and their families face the same systemic problems and clinical risks the English, Swedes and Finns are now scrambling to correct.

The explosive growth in gender-questioning patients and gender-affirming services in Australia closely retraces the English trajectory. But we started a few years later, so there is time to learn from England’s mistakes.

English medical authorities were forced to awaken by years of testimony from clinical whistleblowers, traumatised patients, and their families. The Cass Review followed books, media attention and legal cases, describing a health service heavily influenced by trans activist groups who infiltrated clinical units as patient advocates and supports.

Health staff reported they felt pressured to ignore signs of medical and mental illness in order to focus exclusively on gender, a process called diagnostic overshadowing. Even more damning, Cass reveals that gender-affirming providers ignored their own research, rapidly expanding access to dangerous medications such as puberty blockers even after finding there were no benefits.

The usual health system safeguards failed to detect this violation of the first principle of medicine: do no harm. Instead, problems were only identified because individual patients and staff had the courage to speak out over strong social and bureaucratic pressure to remain silent.

As well as ignoring their own research, English gender services actively refused to co-operate with official efforts to analyse existing data. This prevented investigators from getting a better picture of who was being treated, what was being done to them, and what the outcomes were.

While speculative, it seems unlikely that services would have refused to participate in research if they were confident it would show patients were significantly more helped than harmed by gender-affirming treatment.

Although these advance warnings should be good news for the health and safety of gender-questioning Australian kids and their families, our gender services do not seem to be listening. Instead, in many cases, they are making up for lost time by implementing more aggressive versions of the practices being shut down in England because of risks to patients.

For example, the Cass Review explicitly identifies “informed consent” models, similar to one being rolled out in Victoria, as incompatible with responsible medical practice. This type of model is grounded in political activist theory more than medicine. It views assessment of the gender identity of gender-confused teens as an illegitimate form of “gatekeeping” designed to control patient behaviour, instead of a medical safeguard protecting their health.

Under this model the doctor’s only role is to confirm that patients understand proposed treatments. Once confirmed, doctors must deliver any treatment the patient requests, without further assessment.

This contradicts the traditional medical approach, in which a comprehensive assessment, including the assessment of gender identity, is a non-negotiable feature of competent and ethical treatment of gender dysphoria. Even more concerning is that the “informed consent” model in Victoria is reportedly being extended to allow GPs to medicate transgender kids without specialists, going well beyond the safe limits recommended by Cass.

It may seem strange that Australia’s gender services are so keen to implement and go beyond risky treatments being shut down all over the world, but it is consistent with what is known about the gender-affirming care movement. This is a well-organised, well-funded international network of clinicians and activists committed to advancing a specific agenda.

Those interested in the details should seek out the report compiled by publisher Thomson-Reuters for gay rights organisation iglyo in 2019 called Only Adults?

In brief, the report compares international efforts to overcome strong public dislike of trans activist goals such as legislation enshrining the right to unconstrained gender self-identification in law, replacing biological sex with gender as the basis of legal rights, and the elimination of barriers such as lower age limits for non-traditional gender identities and treatments.

Based on case studies across Europe, the report recommends trans activists take a strategic approach to achieve their goals. Reflecting on evidence that increased public awareness of trans ideology tends to increase public resistance to it, the report recommends avoiding scrutiny by limiting contact with media and focusing efforts on influencing key decision-makers rather than attempting to change public opinion.

A core part of the strategy relies on establishing gender self-identification legislation as a legal foot in the door that can be leveraged to achieve many other trans activist goals.

The stakes are high, and not just for trans people. A case in Federal Court this week provides a perfect example, where a woman, Sally Grover, is defending her right to define for herself what a woman-only space means. The other party is a transgender woman, Roxanne Tickle, who is effectively claiming transgender women should have all the same rights as biological women, and be able to enforce those rights in court.

The rapid expansion of gender-affirming care, despite the limited evidence of benefits and the certain knowledge of harms, is consistent with this type of strategy. High-quality healthcare relies upon the integrity of the medical authorities who write the blueprints used by hospitals and health services to build their clinical services. This can work very well when the blueprints are written by independent experts who exercise methodological rigour focused purely on patient health outcomes. It can be deeply problematic when the small committees that write the blueprints are co-opted by people with ulterior motives.

Unfortunately, as confirmed by the Cass Review, the blueprints used to create gender services in Australia (endorsed by the WPATH and AusPATH organisations) scored very low on both methodological rigour (26 per cent and 19 per cent respectively) and editorial independence (17 per cent and 14 per cent).

Close examination of these blueprints suggests the primary goal of gender-affirming care in Australia is not to improve the health of gender-confused kids but to ensure they have the right to gender self-identification, and that public health services affirm that identity with support, resources, and medical and surgical interventions.

The rapid expansion of gender-affirming care to increasing numbers of gender-confused kids in Australia, despite the gaps in knowledge, represents a significant failure of leadership. While the reflex is often to blame politicians for systemic failures, medicine’s claim to expert authority in matters of health suggests political solutions will not be possible until the medical profession in Australia follows England’s lead and initiates a comprehensive review of gender medicine.

Dr Andrew Amos is the Queensland chair of Rural Psychiatry at the RANZ College of Psychiatrists.