On November 30, the Full Court of the Family Court of Australia abrogated its responsibility for the approval of the administration of cross sex hormones to children suffering from ‘gender dysphoria’.
It surrendered that responsibility to small groups of protagonists in various children’s hospitals in Australia who promote a medical pathway of ‘therapy’ in which the appearances of the natal sex of the child are subsumed in a chemical and even surgical attempt to approximate features of the opposite sex. As seven hundred confused children are reported to have sought help from protagonists at the Royal Children’s Hospital in Melbourne, alone, in recent years, the number of Australian children at risk from massive intervention in their brains and bodies is enormous.
This epidemic of gender dysphoria is a major problem of public health.
How common is the problem?
Childhood gender dysphoria is described as the distress associated with persistent, insistent and resistant identification by a child with the gender of the opposite sex. No one knows why this occurs: there is no proven biological or psychological cause. It is not a new phenomenon. Rare cases are on record from years past.
But now children are reported to be suffering in numbers which are increasing exponentially every year. Protagonists argue that, in the past, the phenomenon was hidden by social attitudes but that, now, access to the internet is providing confidence for children and parents to declare membership in the ranks of the ‘gender fluid’.
Its rarity, however, was confirmed for me, a paediatrician of over 50 years experience, when I polled 28 of my colleagues and found only 12 cases could be re-called from a total experience of 931 years. In 10 of these cases there was severe mental co-morbidity: the other 2 were associated with severe sexual abuse.
I believe this modern phenomenon represents a behavioural fad which is spreading through the community in a contagious manner, fanned by an uncritical and enthusiastic media, and given direction by websites and such governmental directives as the so-called ‘safe schools programme’. The problem obviously affects children but also, strange to say, parents, especially some mothers who seem prone to become so enmeshed they emerge as cheer leaders in the transition of their offspring.
In many ways it is a more dangerous challenge to public health than, say, tuberculosis which is much less common and usually responsive to a relatively short course of antibiotics. Treatment of childhood gender dysphoria may involve entry onto a medical pathway of ‘treatment’ that may affect the child’s brain, body and psychology for as long as it lives, under a lifetime of medical intervention, and a 20 to 30 fold vulnerability to suicide.
The medical pathway may begin with ‘social transition’ in which the child is permitted if not encouraged to emulate the perceived characteristics of the opposite sex. This will involve haircuts and clothing, but also new names to fit identification at schools and access to cross-sex toilets and activities. The danger of this charade is that the child may become so programmed in self identification that progression to the next stages is automatic.
Having been encouraged to identify as the opposite sex by the most powerful influences in its life (parents, family and school), the child may feel the need to suppress its own misgivings as its own hormonal influences begin to question the adopted identification in puberty.
The next stage in the medical pathway is the administration of chemicals which block the complex sequence of hormones that begins in the brain and leads to the maturation of the gonads and the development of secondary sex characteristics. It is known as Stage 1 because it is the first time drugs are administered.
Known as ‘puberty blockers’, these drugs have been given to Australian children from the earliest signs of puberty. One child who sought the external appearances of a girl was given them at 10 ½ years of age.
The sequence of hormones begins deep in the brain in accordance with an unknown biological clock and progresses to stimulate the pituitary gland (at the base of the brain) to produce and release other hormones that travel to the gonads to induce their maturation and the release of oestrogens or testosterone. Protagonists for the drug treatment of gender dysphoria argue the ‘blockers’ are necessary to provide the confused child with more time to contemplate its gender and procreative future, and to delay the appearance of sexual characteristics with which the child may be uncomfortable.
Since the epidemic of gender dysphoria emerged in the early 2000’s, protagonists for medicalisation have argued the effects of blockers are ‘safe and entirely reversible’ and this doctrine has become fundamental to considerations by the Family Court. The problem for the doctrine (in anyone who wants to read) is the existence of laboratory evidence of lasting mal-effects on the limbic system in the brains of animals administered blocker in puberty.
These studies had been stimulated by strong suggestions of mal-effect in human adults receiving blockers for such ill illnesses as prostate cancer in men and endometriosis in women.
In the sequence of hormones released during puberty, it appears the particular hormone blocked early in the process (known as gonadotrophin releasing hormone, GnRH)) has effects in the brain other than the specific role of stimulating the pituitary gland. It appears to have a general role in the preservation of the integrity of nerve cells elsewhere in the brain, the spinal cord, and the neuronal plexus around the bowel. For example, in adult women receiving blockers for gynaecological reasons, degeneration has been demonstrated in the nerves of the bowel.
Failure to preserve the health of neurones may explain the lasting changes in the limbic system in the brains of sheep. That system, reckoned to be the site of the ‘emotional soul’ of an animal, coordinates cognitive, emotional and remembered data and leads to ‘executive function’: in other words, the limbic system initiates a decision for activity that is considered to be the best interests of the animal according to all the various inputs of feelings, memory, and current intellectual judgement.
After a short time on blockers, the limbic system of sheep has been shown to hypertrophy, in the process of which the functions of hundreds of genes are altered. As a result, the ability for executive judgement by a sheep is reduced and emotional lability is increased.
These effects have been publicised over a number of years by researchers in major universities in Glasgow and Oslo. Yet protagonists for the administration of blockers to Australian children have never brought them to the attention of the Australian courts, let alone public. Protagonists continue to proclaim safety and reversibility and acceptance of the allegations has been fundamental to Australian courts.
Even earlier than these specific studies on the action of GnRH, a generalised effect on the brains of animals had been demonstrated in various laboratories. For reasons yet unknown, the injection of GnRH into sites of the brain other than the pituitary has lead to appropriate sexualised behaviour in recipients, even in castrated animals. These experiments have revealed some kind of general influence on gender development of the animal that was distinct from the hormonal sequence that stimulated the gonads.
Why are blockers given to children? Remember: it is to permit them time to consider what gender they would like to be. But, how can they be expected to develop a mature concept when their limbic system is being affected, and they are deprived of the general sexualising influence of GnRH on the brain, as well as the specific influences of sex hormones released from stimulated gonads?
Stage 2 therapy: cross sex hormones
The next stage on the medical pathway, Stage 2, involves the administration of sex hormones to encourage the appearance of the opposite sex.
Protagonists declare certain physical effects to be irreversible, such as the development of an Adam’s apple in a girl on testosterone, and until November 30, the authority of the Family Court was required for their administration to young teens and children, in order to protect the child from, amongst other things, sincere but misguided interventions by therapists. That authority is now abrogated. The administration of cross sex hormones is given to protagonists and parents.
As well as irreversible effects of certain physical manifestations and the probability of sterilisation, protagonists have declared the possibility of disruption of the metabolic systems of recipients resulting in hypertension and thrombosis. But no warning has ever been published or brought to the attention of the Family Court with regard to the proven effect of cross-sex hormones on the brain.
Men on oestrogens have demonstrated a rate of atrophy of grey matter 10 times faster than normal ageing. Females on testosterone have revealed thickening of that layer. Both effects have been demonstrated after only months of treatment. Children may be started on cross sex hormones in puberty, to continue them for the rest of their lives.
Stage 3 therapy: surgery
This stage comprises irreversible surgery to attempt to reduce natal sex anatomy while trying to create the appearance of the opposite sex. International recommendations suggest this should not be done until the child reaches 18 years of age but, in Australia, five girls have undergone bilateral mastectomies in the attempt to emulate the opposite sex. Two were aged 15, one 16 and two seventeen.
Protagonists proclaim these massive chemical and surgical interventions are necessary for the psychological well being of the child who has allegedly been born in the body of the opposite sex. This gender misplacement, however, is declared not to be a pathological phenomenon but merely a point on a normal rainbow of gender fluidity. This sophistry in which a person possesses a normal mind and body but otherwise requires a lifetime of medical intervention has bewitched the Family Court of Australia, and is poised to bewitch the powers that will cause the tax payer to underwrite the normal/abnormal, therapeutic/non-therapeutic life time of support.
The involvement of the Australian legal system may be traced back to a case in 1992 in which the parents of a mentally retarded girl, “Marion” sought authorisation to consent on her behalf to consent for removal of ovaries and uterus to relieve the stresses of menstruation and the possibility of pregnancy. The High Court ruled the parents could not be authorised because the interventions were massive, irreversible, associated with grave consequences of error and were not ‘therapeutic’.
The Court declared it had a protective role for vulnerable children.
Though related distantly to the challenge of gender dysphoria, justices in early courts could discern relevant principles from Marion’s case, especially the matter of whether the medical pathway for gender dysphoria could, in fact, be defined as ‘therapeutic’ when drugs were being administered to physically normal children. Review of early decisions reveals no dispute about the extent of the intervention, and no real arguments have been raised about the gravity of consequences of error. Arguments centred around the possibility of ‘irreversible’ side effects of the medications.
These arguments came to a head in 2013, in a case regarding Jamie, a natal boy seeking female gender. It was decided the Family Court of Australia had no role to play in authorising consent for the initiation of Stage 1 therapy (puberty blockers) because it had been reassured their effects were safe and entirely reversible. This therapy could be left in the hands of protagonist therapists, the parents and the child.
Consent for Stage 2 ‘therapy’ , the administration of cross sex hormones, would, however, need the authorisation of the court if the child was not mentally or intellectually capable of understanding the implications of this therapy. If the child was competent, authorisation of the court would not be necessary. It would remain the responsibility of the court, however, to certify such competence, as guaranteed by involved therapists. In the event the child was not competent to understand and give informed consent, medical intervention would be undertaken on the advice of therapists with regard to what they and the parents considered to be the ‘best interests’ of the child.
Failure of the Courts to really protect the best interests of the child
In none of over 70 subsequent applications to the court for authorisation for administration of Stage 2 therapy, and for the five mastectomies, was it ever mentioned that ‘blockers’ had been revealed to have irreversible effects on the brains of laboratory animals, and that cross sex hormones have evoked measurable alterations in the width of grey material in the brain. Silence on these matters has been unremitting, including the recent Full Court consideration that the protective role of the court should be abrogated.
The Courts seem bewitched by expressed reassurances, and by irrelevant silences. With regard to the grave consequences of error so declared in Marion’s case, Family Court judges have not questioned attestations by protagonists that intervention is necessary. Apparently convinced of the truth of the new philosophy that gender is fluid and flexible, no judge is on record of wondering if the so-called flexibility might mean the child could change its mind.
This kind of wondering was not encouraged by protagonists, as revealed in court documents, who maintained a certitude of strong opinion seldom seen in ordinary medical practice. On the whole, with evangelical essence, protagonists promoted to the judges an upward pathway to be chosen for therapeutic gain and a downward ward hell of self harm and suicide to be avoided.
This certitude triumphed, despite the fact that over half of the confused children had demonstrated prior mental disorder including autism, profound depression and anxiety and even mental retardation. The protagonists appeared undaunted by the long medical history of difficulty in ameliorating personality disorder, especially by chemical and instrumental surgery.
The judges should have considered flexibility, given the grave consequences of entering a child on the pathway of medical intervention for gender dysphoria. Had they so done, they would have surely found assurance in available statistics which declare, time and again, that the majority of children will revert to identification with natal sex through puberty.
If protagonists claims that 1.2% of children suffer from gender dysphoria are true (and I do not accept that statement), the stated prevalence of adults seeking help for gender dysphoria should be profoundly reassuring. According to the 5th edition of the Diagnostic and Scientific Manual of Mental Health, that prevalence is from 0.002 to 0.014 per cent of population, suggesting over 99% of gender confused children will not feel the need for any intervention as adults.
Abrogation of future responsibility
By removing itself from any responsibility for the medical pathway for childhood gender dysphoria the Family Court is abandoning children to a small group of therapists who have failed to bring to the Court’s attention the reality of repeated publications warning of lasting cerebral effects of both blockers and cross sex hormones.
Also, they have failed to bring statistics to the Court that should have warned of grave error in entering the medical pathway because most children would revert to natal sex through puberty. Lastly, the protagonists should have emphasised to the Court that their diagnoses, and treatment, and prognostications were merely based on strong opinion, without any fundamentals of scientific proof.
Marion’s case and some early decisions emphasised the need for the court to be protective of children from such cultural intrusions as female circumcision but also the misguided interventions by sincere medical practitioners. I do not question the sincerity or best intentions of therapists trying to relieve gender dysphoria in children. I would merely raise the absence (and suppression) of scientific proof.
Physical treatment of mental aberrations has a long and sorry history in medicine, despite the sincerity of practitioners. Psychosurgery was once very popular and extensively practiced by a small group of therapists who firmly believed they were helping their distressed patients by boring holes in their heads and severing connections between the frontal lobes and the thalamus.
Chemical and physical reconstruction of the body to approximate the desires of the brain, is a kind of reversed psycho-surgery. Though imperfect, the Family Court of Australia did bring about a certain public accounting for the psycho-surgery of the treatment pathway of childhood gender dysphoria. Now, there will be little accounting as ideology, not science, has triumphed.
Dr John Whitehall is Professor of Paediatrics at Western Sydney University.