Do Clinicians Or Parents Feel Pressured To Affirm Patients?
Senior psychiatrist Dr Jillian Spencer was suspended from clinical duties after expressing concerns about the “affirmation model.”
WHY DO CLINICIANS FEEL THEY’RE BEING PRESSURED?
Several Australian states and territories have enacted broadly worded anti-gender-conversion therapy laws that many gender care providers feel place pressure on them to ‘affirm’ patients, and infringe on their ability to exercise independent clinical judgement.
Many clinicians also find themselves in an environment that discourages open dialogue. Clinicians who question the gender-affirming model have been stood down or subjected to complaints, including clinical psychologist Dr Sandra Pertot and child psychiatrist Dr Jillian Spencer:
“We entered our field to try to assist children to thrive, but the gender clinics have been set up, and psychiatrists are being forced to affirm the social transition of all children…” - Dr Jillian Spencer
The experience of Australian clinicians mirrors that of clinicians in the UK, as was reported by Dr Hilary Cass in a systematic review of the UK’s gender-affirming treatments and services. In her final report, Dr Cass wrote:
“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”
What has been the effect of anti-gender-conversion legislation on clinicians?
Conversion therapy is a cruel practice that aims to suppress or change a gay person's sexual orientation.
Several Australian states have now enacted anti-conversion therapy laws that not only prohibit gay conversion therapy, but that also include broadly written prohibitions on practices that may attempt to ‘change or suppress’ a person’s ‘gender identity’.
The loose wording of these laws has made gender clinicians fearful that they may be open to prosecution, should they assess that a patient doesn’t have gender dysphoria.
In their paper, Evolving national guidelines for the treatment of children and adolescents with gender dysphoria: International perspectives, Kozlowska et al., summarise how the wording of anti-conversion therapy laws may be preventing children from accessing proper psychological evaluation:
“A common feature of conversion laws is to define what is included and excluded in the range of prohibited practices, although the wording of these laws may nevertheless leave unclear which therapeutic practices are permitted and which are not.Some of these laws, such as the Australian state of Victoria’s recently adopted Change or Suppression (Conversion) Practices Prohibition Act 2021, leave only narrow windows for psychotherapy regarding gender dysphoria. For example, a permitted practice is one that “is supportive of or affirms a person’s gender identity or sexual orientation” (section 5(2)(a)), and the state’s Fact Sheet distributed in advance of the bill’s enactment specifically notes that “psychological counselling for children with gender dysphoria” would be permitted under the new law (Victorian Equal Opportunity and Human Rights Commission, 2020). Nevertheless, the law also explicitly prohibits “providing a psychiatry or psychotherapy consultation, treatment or therapy, or any other similar consultation, treatment or therapy” (section 5(3)(a)). “
Under Victoria’s legislation, people who are believed to commit a ‘gender-conversion therapy’ practice could face serious fines or jail time of up to 10 years.
As of 2024, anti-gender-conversion laws have been enacted in Queensland, the Australian Capital Territory, Victoria, and New South Wales.
Supporters of these laws have made statements to the effect that they don’t ban clinicians from conducting thorough psychological evaluations or making differential diagnoses. However, in the absence of clarity, many practitioners are still unwilling to take chances.
A former professor of psychology at the University of Sydney has told media:
“Psychologists in Victoria are terrified of practicing non-affirming psychotherapy for children with gender dysphoria.” - Dr Dianna Kenny in the Daily Mail
Concerns about the impact of anti-conversion legislation on clinical independence have existed for several years now. Despite this, there have been no assurances or updates to guidelines confirming that clinicians may be guided primarily by their own judgement when assessing patients.
WHY ARE SOME CLINICIANS RELUCTANT TO AUTOMATICALLY AFFIRM THEIR PATIENTS?
Multiple studies have found higher rates of anxiety, depression, self-harm, ADHD, ASD trauma, abuse, and adverse experiences among young people who present with gender related-distress (See: de Vries, Holt, Strang, Warrier, Roberts and Schnarrs).
Because children who present to gender clinics have higher rates of mental health comorbidities, trauma and neurodivergence than the general population, many clinicians feel they need to conduct a carefull psychological evaluation, in order to carefully untangle gender dysphoria from many other possible causes of a child’s distress.
Gender-affirming treatments can be invasive and have life-long consequences and the diagnosis of gender dysphoria is subjective and contested. In order to ensure that patients are put onto treatment pathways that address the root causes of their distress - whatever it may be - every patient deserves to have a careful, neutral assessment of their situation.
WHAT IS ‘TRANSING AWAY THE GAY’?
Many gender care providers are also aware that many children who present to gender clinics are likely to be gay children struggling with their sexuality.
To a distressed, young gay child, transition can represent the chance to become ‘straight’.
Without careful psychological evaluation, there is a risk that gay children are transitioned before being given the opportunity to grow into happy, self-accepting adults.
The likelihood of gay children being transitioned under the gender-affirming model was so well known that staff a London’s (now disgraced) Tavistock gender clinic were known to joke that there would be ‘no gay people left’ at the rate they were going.
Members of the LGB community refer to this as ‘transing away the gay’; without careful psychological evaluation, there’s a risk that these children are transitioned before being given the opportunity to grown into happy, self-accepting adults.
Many believe that mindlessly transitioning gay children for fear of anti-gender conversion laws is, ironically, a form of gay-conversion therapy.
Care providers now face pressure to affirm their patients on multiple fronts.
Clinicians at the Westmead Children's Hospital have also reported that they feel compelled to hide their true opinions:
"...clinicians (including ourselves) who work in gender services are coming under increasing pressure to put aside their own holistic (biopsychosocial) model of care, and to compromise their own ethical standards, by engaging in a tick-the-box treatment process." - Kozlowska et al. 2021
Many health bodies have often presented unified fronts on the issue of gender-affirming care that belie serious internal divisions.
In 2019, the Medical Affairs Committee of the Endocrine Society of Australia, a sub-specialty college of the Royal Australasian College of Physicians (RACP), objected to endorsing the Royal Children's Hospital (RCH) gender-affirming standards of care.
The consultation process was highly contentious. It was reported that committee meetings devolved into "screaming matches" between experts. There were also accusations that the pediatricians faction consisted of "activist doctors".
Despite the intense disagreement, the RACP ultimately endorsed the guidelines.
In 2020, when the RACP advised the Federal Health Minister that there was no need for a national inquiry into gender affirming care, its advice didn’t inform the Minister of the serious internal divisions that had emerged just one year before.
Do parents feel pressure to affirm their children?
Generally children under 18, must seek the consent of their parents/guardians before gender-affirming treatment commences.
However, like clinicians, many parents feel pressured to affirm their children and proceed with medicalisation:
Parents visiting gender clinicians are often told that withholding treatment raises the risks that their child might self-harm or commit suicide - regardless of whether or not the child has undergone a careful psychological assessment. Many parents have reported being asked the question: “Do you want a live son or a dead daughter?”The issues of gender identity, dysphoria, and medical transition are new and confusing for many parents. Some may not have sufficient resources to explore all their options fully before making a decision.Parents may also be influenced by knowledge of cases in which children who haven’t been readily affirmed by their guardians have been placed in state care, or have applied to have Domestic Violence and Protection Orders taken out against their parents.Concerned parents have also told media that anti-conversions legislation and online messaging can come to bear on decisions about child gender affirmation:
“It feels like the government is interfering in families and personal relationships...It is very enraging to think that. [My daughter] goes online and is told its 'period dysphoria' or 'chest dysphoria' so she must be trans...This law is just promoting that. I don't know how gung-ho [the police and commission] will get about the law. It's so broad and poorly worded.” - An anonymous parent in the Daily Mail.
The Heritage Foundation (USA): The Medical Harms of Hormonal and Surgical Interventions for Gender Dysphoric Children
Do we know if there are risks of withholding transition treatments?
Parents visiting gender clinicians are often told that withholding treatment raises the risks that their child might self-harm or commit suicide.
Parents may also be asked the question: “Do you want a live son or a dead daughter?”
Top adolescent psychiatrist at Finland’s Tampere University Hospital Dr. Riittakerttu Kaltiala has said that it’s “most unethical” to frighten parents with unproven claims about the risks of not providing gender-affirming care, as parents faced with these claims may feel pressured to say ‘yes’ to a transition treatment plan, rather than risk delay.
Warnings about self-harm should only be made if there are very strong, consistent findings to back them up, but estimates on the prevalence of suicide of patients who don't receive medical transition treatment are contested and variable.
THE CONDITIONAL FALLACY
It's important to recognize that concerns regarding the risks of withholding gender-affirming treatment are based on a specific assumption: withholding gender-affirming care can only be deemed risky, on the condition that patients have been thoroughly evaluated as being in need of gender-affirming care and not an alternative treatment. However, the Gender Affirmation Model is ill-equipped to carefully evaluate patients precisely because it assumes that all patients must be rushed into treatment, lest they harm themselves.
The RCH gender-affirming treatment guidelines say:
" Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications. " - RCH guidelines, p5.
SUICIDE IS COMPLEX AND CAN RARELY BE ATTRIBUTED TO ONE CAUSE
In a cohort that experiences such unusually high rates of comorbidities, it’s very hard to be definitive about the true cause of their distress.
Good data on outcomes for young people who transition is very limited due to the widespread failure to follow up on long-term patient outcomes and the difficulties of disentangling the role of mental health factors from gender-related distress.
One high-quality review of data from UK gender clinics sought to examine the merits of activist’s claims that restrictions on puberty-blocking drugs led to a rise in suicide by trans-identified patients The review found:
1.The data do not support the claim that there has been a large rise in suicide in young gender dysphoria patients at the Tavistock.2.The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide.3.The claims that have been placed in the public domain do not meet basic standards for statistical evidence.4.There is a need to move away from the perception that puberty-blocking drugs are the main marker of non-judgemental acceptance in this area of health care.
Complicating matters further are warnings that transition regret can also lead to self-harm or suicide:
“Of the dozen or so people I've known over the years who had SRS (sex reassignment surgery), I am the only one left alive. Once they finally stopped running from surgery fix to surgery fix, and finally confronted the uncomfortable truth about gender dysphoria, they choose to end their lives rather than live another day being trans.” - Rene Jax
NO PROFESSIONAL CONSENSUS
As with all aspects of gender-affirming care, there is no professional consensus on the issue of the risks of withholding treatment, and very little open debate.
In the comments section of a Royal Australian College of General Practitioner publication, several doctors have expressed their views on the issue, in plain language:
“One doesn't reduce the suicide rate by affirming delusions. This "timely treatment" - with testosterone - can have devastating and lasting effects on vulnerable and confused youngsters who are being used as pawns and guinea pigs. (by those who morally posture to the absolute detriment of these tragic individuals. They need help, not hormones). In the words and sentiments of Émile Zola:- J'accuse... “
Another says:
“At all times do no harm. This caution usually equates to time. When I had anorexia Nervosa, if my GP had said: you need to eat more for your health and exercise less, I would have felt more suicidal and depressed. If my GP had affirmed my desires to be skinnier and my truth that I was overweight, and told me I should skip more meals and exercise more to achieve my dreams, I would have been overjoyed and very very happy. I would have been affirmed and supported in my desires. I would have been so happy to be thinner. Absolutely happy.”
NEUTRALITY AND SAFE-REPORTING ON SUICIDE
Many are concerned that irresponsible or unsubstantiated claims about suicide go against safe-reporting practices and may negatively influence the behaviours of people already vulnerable to self-harm.
The sensitivities involved and the diverging views on this issue emphasise the need for high-quality, neutral advice that assists patients and families to interpret and evaluate different possibilities without unnecessary alarm.