Is The Diagnostic Process Reliable?
Gender-affirming models recommend treating a problem of the mind — ‘gender dysphoria’ — with treatments that change the body. Treatments can be invasive and risky.
Gender dysphoria is an evolving and contested concept.
Australian treatment guidelines define gender dysphoria as “distress experienced by a person due to incongruence between their gender identity and their sex assigned at birth.” RCH p.4
The gender-affirming model proposes that if someone feels that their appearance isn’t aligned with, or is too aligned with sex-based stereotypes, they should receive hormonal or surgical interventions to alleviate their discomfort.
Because gender dysphoria and gender identity are subjective constructs, clinicians have to rely on patient’s self-reporting in order to diagnose.
Uncertainty about the diagnosis of gender dysphoria has persisted over time, despite ongoing research and clinical experience in the field. In 2017, treatment guidelines from the US-based Endocrine Society openly acknowledged:
"With current knowledge, we cannot predict the psychosexual outcome for any specific child."
This uncertainty has persisted. Seven years on from the publication of the Endocrine Society’s guidance, one of the largest reviews into the safety and efficacy of gender-affirming care, The Cass Review, found:
“The evidence is weak and clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.”
Does the Gender Affirming Model teach to stereotypes?
The gender-affirming model’s focus on appearances, performativity, sex and gender has given rise to concerns that teaching the idea of gender identity to children at a young age may in fact reinforce stereotypes, rather than deconstruct them, as many advocates claim.
On this question, it might help to consider some examples of gender-affirming materials presented in schools or medical settings:
At a glance, gender identity or queer theory might seem as though it challenges sex-based stereotypes. For example, resources from Safe School Coalition Australia, 'All of Us' asks children the question:
"Who decided that all boys and only boys like playing with cars and in the mud? Who makes these rules?
However, you might notice that the theories presented in these resources only challenge the idea that all males have to subscribe to male stereotypes and vice versa — they don't challenge the stereotypes themselves.
Ultimately, gender identity theory suggests that sex and gender-based stereotypes are mapped onto one another and that therefore, a girl who enjoys stereotypically 'male activities', like playing with cars, can be considered to be a boy, because she is acting or identifying with behaviour that the theory considers to be intrinsically 'male'.
The question the ‘All of Us’ materials don’t ask is: Who decided that playing with cars makes a girl a boy, instead of just a girl who likes to play with cars?
Instead, the 'All of Us’ materials go on to discuss a video about 'Nevo' a girl who becomes a 'he' after making her external appearance more ‘masculine’:
"Nevo was raised as a girl and grew up feeling that this did not match who he really was. He is undergoing a transition, medically and socially, to make his external appearance more masculine and to make his life better reflect how he feels inside. This is also known as affirming one’s gender identity."
Because 100% of people do not conform perfectly to male or female stereotypes, children who accept the framing presented in these resources could easily come to see themselves as being in need of ‘gender affirmation’, when in reality they are just perfectly normal, complex human beings.
In our list of Questions to challenge Affirming Care we suggest asking the following:
Which of these statements do you agree with more?
A. If a boy likes playing with dolls, that's totally ok. Both boys and girls can express themselves in a wide range of ways.
B. If a boy likes playing with dolls, he's a girl.
Does Diagnosis rely on patient self-reports?
Australian treatment guidelines provide very little information on how to accurately diagnose gender distress or distinguish it from other mental health issues.
Instead, they encourage clinicians to rely on their patient’s self-diagnoses:
“To nurture affirming medical spaces, it is imperative services understand that trans patients are the experts of their own lives and the final authority on their gender." ICS p7"Informed consent models of hormone prescribing resist the notion that a doctor can determine the validity of a person’s gender, and instead center the trans person in the decision-making process... ". ICS p7“...decision making should be driven by the child or adolescent wherever possible, and this applies to options regarding not only medical intervention but also social transition". RCH guidelines, p5.
Some Australian guidelines reference international diagnostic standards found in the DSM 5 or WPATH guidelines, but all tests for gender dysphoria are reliant on patient’s subjective self-appraisals.
IN 2019 DR TELFER, LEAD AUTHOR OF THE 2018 RCH TREATMENT GUIDELINES, TOLD A ROYAL COMMISSION INTO VICTORIA'S MENTAL HEALTH SYSTEM THAT MENTAL HEALTH CLINICIANS AREN’T NEEDED TO DIAGNOSE GENDER DYSPHORIA:
“Q: Is there a misconception in some parts that the role of the mental health clinician is to diagnose gender dysphoria?Dr Telfer: Yeah, it's really interesting when we think about mental health clinicians within the context of trans and gender diverse children, because you don't really need someone to diagnose a person with gender dysphoria, because a trans identity is something that's so innately personal that really only that young person or adult, depending on what time of their life they're coming in, only they know how they feel about their gender and whether that's a problem or not for them.” - Dr Telfer, 2019
Can Clinicians distinguish between a trans identity and other mental health conditions?
Patients who seek gender care have higher rates of mental health comorbidities, same-sex orientation, trauma and neurodivergence than the general population.
In order to determine the direction of causality between a patient’s mental distress and their discomfort with their sex or body, care-providers need to conduct careful exploratory therapy.
Despite this, gender affirming treatments downplay the importance of conducting a thorough psychological evaluation, and warn that delaying care is inherently risky:
" 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.
These warnings are presumptuous however; in order to know if a child was in urgent need of gender-affirming care (as opposed to another treatment) the child would first need to undergo a thorough psychological evaluation.
SELF-REPORTING AND SUBJECTIVITY
Gender dysphoria (also called gender incongruence) and gender identity are subjective constructs that rely on patient’s self-reporting. There is no empirical, standardised diagnostic process for gender dysphoria and no way for a doctor to confirm if a diagnosis is correct.
This increases the chance of unnecessary medical interventions and makes the accuracy of the treatment model impossible to evaluate.
RED FLAGS
Self-reporting is unfalsifiable (a claim that’s not possible to be proven wrong with material evidence). An over-reliance on patient self-reporting their levels of pain was a factor contributing to the opioid epidemic in the USA.
Besides gender dysphoria, are there other reasons why a child might present with distress around their sex or gender?
Prior to the popularisation of gender-affirming care, the conventional wisdom was to provide ongoing exploratory therapy and to monitor young patients carefully as they developed. Doctors who have worked with young patients in this manner for decades are well aware that there are many reasons other than gender dysphoria that can cause young people to feel uncomfortable in their bodies:
“For almost all of the Gender Identity Disorder/ Gender Dysphoria patients I have seen, there were clear (but different in each) family issues which made choice of the opposite gender an understandable response Problems ranged from relatively uncomplicated sibling “favouritism” to risks of sexual abuse, (real and perceived). In many, there was a strong history of inter-generational sexual abuse, domestic violence, and/or high occurrences of tragedy for either males or females in the family. Dealing with these issues with the patient and family members both resolved the gender issues, and improved family functioning. “ - Adolescent & Family Psychiatrist Dr Cary Breakey
A range of alternative diagnoses published in a November 2015 edition of Australian Family Physician includes body dysmorphic disorder, autism spectrum disorder, psychotic disorder, and borderline personality disorder:
The Royal Australian and New Zealand College of Psychiatrists’s position statement now stresses the importance of exploratory therapeutic approaches.
“Distress associated with gender may in some situations be related to a range of psychosocial issues or mental health conditions.”“It is important that TGD people are able to access a range of services including psychotherapy and psychosocial support.”
CAUSE, EFFECT AND MOTIVATION
Bidirectional ambiguity refers to a situation in which there is a correlation between two variables, but it's unclear which variable is influencing the other, or if they are mutually influencing each other.
For example, a person’s desire to be recognised as the opposite sex (or to take on a ‘non-binary’ presentation) could be both the cause or the result of another type of mental distress, like body dysmorphia or depression.
Relatedly, it’s also important to consider the concept of approach motivation versus avoidance motivation. Is a child running towards the opposite sex (approach motivation)? Or, are they actually just running away from their own sex or body (avoidance motivation)? Could this be because of trauma, or a discomfort with their sexual orientation?
Gender-affirming care is incurious about these questions, or any other that might divert a patient from the path of gender affirmation.
Are people ever misdiagnosed?
Yes. For a full overview, see our Detransition, Desistance, Regret page.
Stories of patients harmed by gender-affirming care have risen steadily in the past 5-10 years.
Among them are a growing number of Australian detransitioners including Jay Langadinos Courney Coulson, Ollie Davies, and former patients featured on Channel 7’s De-transitioning.
The rise in legal actions from detransitioners across the USA has been also covered in The Economist.
Even doctors who helped lay the groundwork for gender-affirming practices have begun speaking out about the pain the model is causing.
In the article, Gender-Affirming Care Is Dangerous. I Know Because I Helped Pioneer It, adolescent psychiatrist Dr Riittakerttu Kaltiala said:
"It is devastating to speak to patients who say they were naive and misguided about what transition would mean for them, and who now feel it was a terrible mistake. Mainly these patients tell me they were so convinced they needed to transition that they concealed information or lied in the assessment process."