Gender doctors ‘pressed to give drugs’

Clinicians are under increasing pressure to enable ‘conveyor belt’ medicalisation of children, according to a landmark study.

Researchers say family conflict may be entangled in what presents as a child’s distress about gender. Picture: iSTOCK

Gender clinicians are under increasing pressure to enable “conveyor belt” medicalisation of children who arrive already convinced that hormonal drugs are the only solution to their distress, according to a landmark study.

The first paper from Australian gender clinicians to tap into international concerns about the “gender affirmative” medicalised treatment model for gender dysphoria suggests that young people are often not open to exploring other possible factors in their distress, such as family trauma, sexual abuse, depression and autism.

Gender dysphoria is the sense of a distressful disconnect between an inner sense of “gender identity” and the body shaped by biological sex. Youth gender clinic caseloads have exploded in affluent countries, and there is intense debate about the causes and how best to respond.

A simplistic focus on gender alone “is likely to promote a healthcare delivery model that dehumanises the child by not examining the child’s and family’s lived experience, and that promotes medical solutions … for a problem that is much more complex,” says the paper involving gender clinic staff from The Children’s Hospital at Westmead in Sydney.

Tasmanian Liberal senator Claire Chandler, who has rebuked state and territory health departments for failing to release children’s hospital patient data to enable open debate about gender clinics, said the Westmead paper was significant.

“(It’s) so important because it backs up all the concerns that have been raised by doctors, parents, psychologists and detransitioners about the way children are seeking and being given major medical interventions without having an adequate understanding of alternatives,” she told The Australian.

Psychiatrist Roberto D’Angelo, who uses psychotherapy to help young clients cope with gender dysphoria, said the paper ­appeared to be the first from a group of Australian gender clinicians willing and experienced enough to grapple with the complexities of treating young people presenting with gender distress.

Dr D’Angelo, a director of the international group the Society for Evidence-Based Gender Medicine which campaigns for ­robust research to offset the low-quality evidence underpinning the affirmative treatment model, said the Westmead paper was “a very significant validation of the concerns that we have been writing about”.

‘Unresolved trauma’

The Westmead researchers urged a shift in care towards a more comprehensive “trauma-informed model of mental health care” allowing children time and space to explore all the issues, and safeguarding the ethical standards of the clinicians from the risks of a “tick-a-box” medical model.

Their study cites Dr D’Angelo’s work, as well as advice from UK “detransitioner” Keira Bell, 24, whose litigation against Britain’s Tavistock gender clinic led to a 2020 English High Court ruling that ­puberty blockers to interrupt ­unwanted sex development are “experimental”.

The judges said children under 16 would struggle to give informed consent to such a potentially life-changing intervention. An appeal by the Tavistock clinic will be heard in June.

Ms Bell, who was put on the affirmative medical path at 16, told the Sydney researchers that young people with dysphoria needed “psychological support from impartial practitioners who do not subscribe to gender identity ideology and are able to help people explore their thoughts and feelings about their sex, sexuality and the underlying causes of their gender dysphoria”.

The Westmead researchers said the stories of detransitioners who came to regret trans hormone drugs and surgery “highlighted that children, families, and clinicians had no reliable way of ascertaining whether a child’s decision to engage in irreversible medical interventions for gender dysphoria would prove to be ‘right’ or ‘wrong’ in the long term for that particular individual”.

They said the evidence base for puberty blockers and cross-sex hormones was “sparse and contradictory”.

A fascinating, early exploratory study of the experiences of detransitioners. Such a study can give no insight into prevalence - but it can be very valuable in highlighting areas that require more study. Well worth reading in its entirety https://t.co/9kp5mqQDc8

— Helen Joyce (@HJoyceGender) April 30, 2021

The Westmead paper notes that after Australia’s Family Court made it easier for minors to get irreversible cross-sex hormones in the 2017 re Kelvin case — a decision that was hailed as a triumph for trans health rights — NSW ­clinicians came under pressure to abandon a wholistic psychological approach and to prescribe these hormone drugs for children as young as 12.

“A large subgroup of children equated affirmation (of their transgender identity) with medical intervention and appeared to believe that their distress would be completely alleviated if they pursued the pathway of medical treatment,” the paper says.

This was not only the influence of the dominant affirmative treatment model but also reflected outside factors including previous health workers, the internet and youth peer groups, the paper says.

“Many children arrived at the clinic with strongly entrenched beliefs and with no interest in further exploring their medical, psychological, social, or familial situation.”

The researchers who ran the 2013-18 study at the Westmead gender clinic — involving 79 young people with a median age of 13 — say it became clear to them “that many children did not have the cognitive, psychological, or emotional capacity to understand the decisions they were making”.

As clinicians, they say they felt frustrated in seeking to go beyond the gender fixation of the child and family to work out how the young person’s distress might be affected by other issues such as parental conflict, abuse, maltreatment, depression, often undiagnosed autism or psychosis.

“Lost were our efforts to highlight the many different pathways in which gender variation could be expressed, to explain potential adverse effects of medical treatment, to explore issues pertaining to future fertility and child rearing, and to highlight the importance of ongoing psychotherapy,” they say.

This interview with David Bell, the whistleblower who sounded the alarm about the Tavi’s Gender Identity Development Service, is a powerful & important piece of journalism by @MsRachelCooke in today’s Observer. A couple of thoughts prompted by it...1/6https://t.co/aWKEeMbpLt

— Sonia Sodha (@soniasodha) May 2, 2021

A mother whose child was a Westmead gender patient, after this landmark study finished, claimed the promise of a wholistic and careful approach had proved illusory.

“I raised many of the concerns outlined in the research at an assessment appointment, such as complex family dynamics and mental health challenges,” she told The Australian, speaking on condition of anonymity.

“Despite the number of red flags and clinicians’ own concerns, within six weeks the child was diagnosed with gender dysphoria. Within another couple of months, the clinic prescribed puberty blockers.”

She said it was “concerning” that the Westmead researchers were still claiming the effects of the off-label drugs used to block puberty were “temporary and reversible”.

In June last year, the UK NHS quietly abandoned its online claim that blockers were “fully reversible” and admitted uncertainty about their effects on “development of the teenage brain”.

In their Tavistock ruling the judges said the claim of reversibility did “not reflect the reality” that almost all children appeared to graduate from blocker drugs to irreversible cross-sex hormones.

Video: Oxford University sociologist Michael Biggs on puberty blockers

In Westmead’s study, there were high rates of anxiety, depression, suicidal ideas, behavioural disorders, autism and “adverse childhood experiences” such as family conflict, exposure to domestic violence, parents with mental illness, loss of important figures through separation, and bullying.

“(Yet) families tended to medicalise the child’s distress, attributing it solely to gender dysphoria as an isolated phenomenon, with the consequence that the family identified the medical pathway as providing the only potential way forward,” the paper says.

Sometimes, the researchers say, the decision to seek gender clinic medicine appeared to be a parent’s agenda, not the child.

Dr D’Angelo said the study confirmed the cultural obstacles for psychotherapists trying to help a young person think deeply about the causes and context of their distress.

“There is so much social reinforcement for adopting the idea that gender dysphoria is an issue that (generally requires) biomedical intervention (such as hormonal drugs),” he said.

“The young people that we see have been immersed in this kind of way of thinking about themselves from a very young age, and it’s reinforced by the media, by what kids read online, it’s reinforced now by what kids are talking to each other in schools — it’s really become a social reality.”

The Westmead children’s hospital offers puberty blockers as the first stage of medicalised gender change, and patients seeking cross-sex hormones are referred to adult/adolescent services as they near the age of 16, the paper says.

A spokeswoman for NSW Health said the agency “supports access to multidisciplinary care for children and adolescents with gender dysphoria that is consistent with Australian and NSW laws and policies.

“This care is also informed by endorsed national and international clinical guidelines and the best available scientific peer-reviewed evidence, including appropriate safeguards.”

The Australian sought comment from NSW Health Minister Brad Hazzard; the pro-affirmative gender clinicians’ group, the Australian Professional Association for Trans Health; the Westmead researchers; and the support group Parents of Gender Diverse Children.