We need gender-affirming care to be returned to being part of person-centred care, where healthcare professionals can work with individuals and families to find the best intervention for each individual.
Just over a week ago, I started seeing posts on my YouTube feed from right-wing websites gloating over the latest Family Court judgment and suggesting that this was the end of the road for puberty blockers in transgender kids.
It wasn’t until almost a week ago when an article appeared in Ausdoc, that I finally got to read what this latest judgment was about.
I am writing this article as a GP who does a lot of work with the trans community. Like everyone who works in this area, I have seen the transformative effects that access to puberty blockers and gender-affirming hormone treatment have on adolescents with gender incongruence.
The euphoria that these young people express when they finally manage to battle through all the hurdles they have to overcome to get the treatment they need, is something one rarely experiences in any other field of medicine.
Now, I don’t have access to all the court documents so what I write now is based on the reporting from one article. But, from the perspective of someone who works in this area, there are so many errors and incorrect assumptions made by the judge in this case that I feel the need for correction.
The judge criticised the gender service that had treated the child called Devin as “essentially a pathway for a single treatment”.
This criticism echoes what the Cass Review said about the Gender Identity Development Service base at the Tavistock Clinic in England. For a response to concerns about the Cass Review and the subsequent developments in England, I would direct you to these statements by AusPATH (here, and here).
The judge then criticised the psychologist at the gender service who looked after Devin. This psychologist had seen Devin 15 times over a four-year period.
The judge rejected a diagnosis of gender dysphoria by the psychologist. This rejection was justified on the basis that the psychologist had not completed a biopsychosocial or autism assessment.
To me, this reads like a judgment that implies a biopsychosocial or mental health causation for gender dysphoria.
While we all know that people with gender incongruence have more mental health diagnoses and suffer more adverse biopsychosocial outcomes, there is no evidence that these are causative factors for gender incongruence. Having a biopsychosocial and autism assessment adds completeness to the mental health assessment but doesn’t invalidate a diagnosis of gender dysphoria or gender incongruence, which is an entirely different matter altogether.
The judge also remarked that the fact that the psychologist had recorded a diagnosis of gender dysphoria shortly before the court hearing was “more than merely coincidental”.
Again, this judgement to me discloses a lot of ignorance about the assessment process by a psychologist. There is no right or wrong time to make a diagnosis of gender dysphoria. Gender identity itself as well as an awareness of it can evolve over time.
Would the judge have also criticised the psychologist for making a premature diagnosis if she had made a diagnosis of gender dysphoria when she had first seen the child when the child was 7 years old?
The judge also criticised the impartiality of the psychologist when she admitted that “it was hard to read” reports from the father’s expert witnesses.
As someone who works with the trans population, I too, find it hard to read the reports from medical professionals who oppose gender-affirming care. I imagine that for the psychologist, having worked with this child for over four years, she must have been very worried about the consequences for the child if the child were to be handed over to the custody of the father based on the expert witnesses he had used.
Judge Strum then went on to say that he regarded puberty blockers as posing “an unacceptable risk” to Devin. He made the interesting point that puberty blockers would lead to a permanent micropenis that would interfere with sexual function regardless of what gender Devin eventually chose to be. That even if Devin chose to be female, it would cause insuperable problems for surgical affirmation.
I wonder where Judge Strum got his medical advice from.
Related
It is true that doctors working in the gender affirmation area do discuss the possibility of permanent infertility with our patients. That is because the gonads are still immature at Devin’s age and it is unclear how their development might be affected later on.
If Devin chose to stop puberty blockers at some stage and allow testosterone production to resume, penile development would resume. And if Devin chose to go on feminising treatment, there are now many people who have already trod the path that Devin would go on who have had successful peritoneal pull-through vaginoplasties to attain functional neovaginas.
Judge Strum then quotes from the Cass Review about his fears about the effect of puberty blockers on identity and sexuality.
Identity and sexuality are complex constructs. Nevertheless, my experience in this area is that young people who have been exposed to puberty blockers go on to have happy relationships and sex lives.
Critics who highlight this concern never mention the psychological harm that young people who are forced to go through puberty that they don’t want, endure. Nor do they mention the lack of any evidence that young people who have been prescribed puberty blockers for premature puberty have problems with their gender identity or sexuality later in life.
He then went on to criticise the director of the gender service, Professor L, for supporting the Australian Standards of Care and Treatment Guidelines because she had co-authored the document.
He said that saying “the guidelines were best practice was essentially tantamount to agreeing with herself”.
I found this criticism extraordinary. Did Judge Strum expect Professor L to repudiate what she had written? Did Judge Strum not expect her to do the best when she was writing a set of guidelines for Australian use?
I found this judgment highly unsatisfactory.
For someone working in this area, it shows many misconceptions and misunderstandings about the whole area of gender-affirming care. It is unfortunate for young people with gender incongruence that gender-affirming care is caught up in the culture wars and weaponised for political purposes.
We need gender-affirming care to be returned to where it belongs – as part of person-centred care, where healthcare professionals can work with individuals and families to ascertain the best medical intervention for each individual.
And maybe, we need government to legislate for that right to exist.
I recently had a conversation with a German specialist about his work with children and families. What he said to families who were uncertain about supporting their kids to transition was this:
“You can support them now and grow your relationship of love and trust with them. Or you can stop them now. But know that when they are old enough, they can do what they want and they will remember what you had done to them.”
I’d like to believe that most Australian parents believe in love and trust.
