A QUESTION OF TRANSITION

Youth gender treatment under scrutiny

This is a piece The Age refused to publish. It is the first in a series I’ll be posting here. 

Shortly you’ll read two accounts from two mothers about their teenage child “coming out” as transgender, and what happened next. They are intensely personal narratives. They should not be taken as typical of the experiences of the thousands of young Australians and their families getting medical treatment for distress about their sex at birth. Nonetheless this tale of two families reveals something about the harrowing and intensifying debate about children and young people transitioning to the opposite sex.

As recently as 30 years ago doctors tried to steer such young people away from identifying as the opposite sex with the aim of “fixing” them. Psychiatrists routinely inflicted untold psychic damage on children who were gender non-conforming or gay or otherwise running afoul of society’s rigid social norms.  

During the past decade a sharply contrasting approach known as “affirmative care” or “gender affirmation” has recast this area of medicine, and with it schools, workplaces, sporting clubs and human rights laws. Plenty of myths surround “affirmative care,” which, its proponents stress, is not a treatment plan but a philosophy. As a philosophy, affirmation demands that clinicians respect, even champion, a gender-incongruent individual’s right to self-determination. 

The concern is that young people are asserting that right in soaring numbers — referrals to children’s gender clinics have grown exponentially during the past 10 years.

It is a trend that has health authorities in some of the world’s most progressive countries baffled, and sounding the alarm about routinely administering to distressed children treatment that has serious and irreversible side effects, including loss of sexual function and infertility. 

Central to this dilemma is mounting uncertainty about whether transition will ease these young people’s anguish in the long term, or merely compound it. 

“Mum, I just wanted to tell you…”

When Melanie Bublyk’s female-born child, Felix, came out as a transgender male about three years ago, she says she was “definitely” not shocked at the announcement. 

“I think this has been a lifelong thing since early childhood,” explains the mother from Queensland’s Sunshine Coast. 

She immediately went about getting Felix support. He saw clinicians at mental health service headspace. Then a high school nurse who “could see Felix was trans from the time he started high school,” recommended he get a referral to the Queensland Children’s Hospital gender service, a one-stop shop for specialised child and adolescent psychiatrists, paediatric endocrinologists, nurses, social workers, psychologists, and speech pathologists. 

Melanie Bublyk and her trans son Felix (family supplied)

About a year after Felix began attending the clinic, a little before his 17th birthday, he went on the male hormone testosterone to masculinise his appearance. 

Bublyk has a master’s degree in human rights from Curtin University. Selected for a United Nation’s women’s empowerment program from more than 600 applicants, she has collaborated with organisations around the globe to fight systemic injustice, and tackled the feminisation of poverty in Australia. Her professional background has trained her to see individual struggles through the lens of structural inequality, and that’s how she views Felix’s struggle for bodily autonomy. Transgender people have “always been there,” she says, fighting to be seen.

She says she did not feel any pressure from doctors to consent to Felix’s hormone treatment. Nor does she believe the clinicians uncritically accepted her child’s declared identity.

“He had lengthy discussions with them,” she says. “They would have known if he wasn’t transgender.” 

“I’ve had concerns as a parent and I’ve asked him (Felix), ‘will you regret this down the track?’ But he’s told me he’s happy and I can see it.”

That happiness has been hard-won. At school Felix had been relentlessly bullied for being different— the torment became so intolerable he left. He ultimately completed Year 12 at a flexible learning centre of the Edmund Rice Foundation, which runs programs for marginalised communities.

“I think if I hadn’t been supportive of him his mental health would have been deteriorating,” Bublyk reflects. “But this is just my experience. I can’t speak for other people.”

Felix is happy to be identified in this story, but he declines the offer to speak for himself. He just wants to get on with his life, his mother explains. 

“He’s not an activist.”

Says Bublyk: “I think as a parent you just know (if your child is transgender.)”

***

“Yvette” would agree, even if her experience as the mother of a child wanting to transition is altogether different to Bublyk’s. About five years ago Yvette was seeing troubling changes in her teenage daughter, “Mia.” The names are fictitious because this mother does not want her child’s story to become a “political football.”

Mia cut her hair short and switched to baggy clothes. She became withdrawn, spending hours online. 

Typical teenage moodiness, Yvette figured, certain she had some authority on the subject.

“I gave my own mum hell when I was a teenager,” she explains wryly. “I was a rebel and a punk.”

The announcement came a few days after Mia’s 16th birthday.

“Mum, I just wanted to tell you I’m trans.” 

The two of them were in the car; Yvette gripped the wheel. 

To her and her husband “John,” this declaration came out of the blue. They couldn’t recall anything from Mia’s childhood that might have suggested she saw herself as a boy; a clinician would later tell them some people only realise they are trans once puberty is underway.

All Yvette knew was that at school Mia had been friendly with a trans student medically transitioning from female to male. 

Desperate to support their daughter, the parents consulted their family GP. He referred them to the multidisciplinary gender clinic at the city’s children’s hospital. 

Yvette does not wish to “cause trouble” by naming the clinic, of which there is one in each mainland capital. We can disclose that it’s not the gender service at Melbourne’s Royal Children’s Hospital (RCH), which, as the country’s largest such treatment centre, finds itself a natural target for people opposed to medically transitioning minors.

Some months after the GP’s referral, Mia had the first of a series of appointments at the gender service, each spaced months apart. For a year and a half, the family engaged with a psychologist — “a beautiful warm lady”. She told Yvette and John that as a cohort transgender children are at high risk of suicide. Naturally, they found this information terrifying.

Next Mia consulted the clinic’s psychiatrist. Yvette was present at the first session.

“When you were little, did you play with girls or boys?” the psychiatrist asked. “Did you play girl games or boy games?”

Mia answered “boys” and “boy games.” 

The picture being painted struck Yvette as false.

“In the end, I don’t think she had more than four or five hours with him (the psychiatrist) in total,” she says. “For him to fucking diagnose her as trans.”

Technically no-one is diagnosed as trans any more than they are diagnosed as its opposite.

Mia’s diagnosis was of gender dysphoria; the distress a person feels when their birth sex doesn’t align with how they see themselves.

Yvette says the clinicians treating Mia helped her socially transition; to dress like a boy, and change her name. One of the treating psychiatrists suggested Yvette might consider “supporting” her child by switching to male pronouns. 

Mia herself was more focused on getting her parents’ support, and legal consent, for medical transition. Coming towards the end of puberty, she was no longer a strong candidate for puberty blockers— drugs that halt the development of secondary sexual characteristics. She wanted to go on testosterone, and was “terribly unhappy and fighting against us, pushing to get it.”

“We said, ‘Okay.’ We had to pull away.”

The family met with the clinic’s endocrinologist who explained that prolonged use of testosterone could compromise fertility. The specialist suggested Mia may want to insure against this risk by freezing her eggs. Her response was emphatic: “I don’t want children!” 

Roughly 20 months after her initial consultation at the clinic, and like Felix, aged 17, Mia gave her consent for hormone treatment. The paperwork warned some effects of testosterone would be “permanent”: deepening of the voice, increased facial and body hair and “possibly” baldness, clitoral enlargement and “possible” mild breast atrophy. 

Extract from the hospital consent form

Yvette wrote a letter of complaint to the head of the clinic. She argued the “affirmative” care model made Mia’s transition a foregone conclusion.

“I understand why they take this ‘gender affirmation’ approach; for a child who is truly trans, it must be a relief,” Yvette says. “But the thing is, they don’t know the individual kid..

“It is terrible, terrible language .. deliberately loading a medical procedure with the connotation that, if you don’t pick that option, you are denying your child their identity. What a load of emotional blackmail.

“I have no doubt my daughter— and I still call her my daughter— believes she’s trans. But … I wanted to ask the psychiatrists, ‘Where is the test that will show that my child is 100 percent trans? You’re asking me to approve of permanent, life-altering changes.. If 10 years down the track this turns out to be wrong, will these psychiatrists be there at 2am when my daughter is struggling to go on?’”

A fraught debate

Despite its dominance as a treatment model for gender dysphoria, affirmative care has critics within the medical profession, and impassioned detractors outside of it. These critics argue gender dysphoria is often a symptom of other psychological problems and should initially be treated with psychotherapy rather than hormones.

As the experiences of Yvette and Bublyk suggest, this is a debate in which every contention — every experience, every study— has its flip side. 

The growing awareness of transgender identity is helping young people experiencing gender distress name their feelings and come forward for help. On the other hand, even some affirmative care practitioners concede that the same awareness is fuelling a social contagion whereby troubled youngsters, looking to escape unwanted aspects of themselves, come to believe they’re “trans.” 

Studies of people who transitioned in earlier decades suggest minuscule rates of regret. But the cohort of young people seeking transition today is markedly different — most are females in their teens, which wasn’t the case in the past — and it’s too early to tell how they will fare. 

Allowing children and adolescents to live as the opposite sex, or as neither sex, sends a powerful message of acceptance and boosts their chances for a lifetime of psychological health, says the affirmation camp. The critics say social transition risks locking in a transgender identity that might otherwise be transient and setting children up to be lifelong medical patients.

The contradictions don’t end there.

Some transgender activists and their allies claim that “detransitioners” -- people who transition only to later stop treatment and reconcile with their birth sex—are being used by the political Right to demonise affirmative healthcare. In reply, some detransitioners and their allies accuse trans activists of “grooming” children to disassociate from their bodies and “come out” as trans. 

In Texas, under a governor’s order instigated last February, parents who seek to affirm their child’s transgender identity by supporting hormonal treatment can be charged with child abuse. Conversely, under a law banning conversion therapy that came into effect in Victoria last February, parents who take active steps to suppress their child’s transgender identity can be charged with a criminal offence.

Finally, to feel intensely at odds with one’s sexed body is no longer deemed a mental disorder. 

Yet many young people turning up at gender clinics today have existing mental health conditions, such as autism, eating disorders, attention deficit disorder, serious depression and trauma. 

Sometimes the competing narratives swirl around the one gender clinic. 

***

Nearly two years ago dissident clinicians — psychiatrists, endocrinologists and psychologists— from the gender service at Sydney’s Westmead Children’s Hospital published a report on “the clinical presentations and challenges” they encountered since the clinic opened its doors in 2013. They found a patient group with high rates of “co-morbid” mental conditions, and “adverse childhood experiences,” including family breakdown and sexual abuse.

The seven authors also describe the clinic as riven and under pressure from “increasingly dominant, polarised discourses” around children with gender dysphoria, including “emotionally charged, one-sided” media coverage. Some clinicians in the team were “more sympathetic” to the gender affirmative model, the authors observed, while others sought a “more neutral” position about their young patients’ complex needs.

Meanwhile, the dominant affirmative care discourse was shaping the expectations of children and families who were arriving at the service with a “conveyer-belt mentality” already convinced that puberty blockers were the only solution to their distress. 

The authors lamented: “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.”

In February the researchers followed up with a study of 79 young people four to nine years after they first presented at the Westmead clinic. Most of the patients diagnosed with gender dysphoria had ongoing mental health concerns after transitioning. Almost one in 10 dysphoric patients, some who had taken puberty blockers and cross-sex hormones, later discontinued transitioning.

The authors say the results cast doubt on the central justification for affirmative care, namely that it relieves psychological distress. What’s instead needed is a “much more nuanced and complex approach” conclude psychiatrist Kasia Kozlowska, paediatric endocrinologists Professor Geoffrey Ambler and Ann Maguire, physician Joseph Elkadi, psychologist Catherine Chudleigh and Harvard Medical School ethicist Stephen Scher. 

The response to the Westmead researchers from Australia’s pro-affirmation gender medicine fraternity is scathing. 

Two affirmative care clinicians, speaking to me off-the-record, described the Westmead authors as Johnny-come-latelies to the field and made unpublishable allegations about the integrity and ethical framework of their research. Another said the report was typical of the reactionary streak in NSW, as “it’s Mark Latham country.” The former Labor leader is a One Nation MP in the state’s upper house: since 2020 he has pushed for legislation banning discussion of “gender fluidity” in schools.

The Australian Professional Association for Trans Health (AusPATH), a body representing more than 450 affirmative care professionals, accuse the authors of the February paper of “significant bias,” methodological flaws and misrepresentations, citing “discredited literature” and demonstrating “a clear agenda … to undermine the provision of gender affirming care to transgender children and adolescents.”

After the medical publication Australian Doctor publicised Westmead’s earlier 2021 report, AusPATH demanded the article’s removal from the website and an apology from the publication. (Australian Doctor’s editor refused to do either.) In a published response, AusPATH alleged that the Westmead clinicians’ research “fits with misleading claims of gender diversity being something other than a very normal variation in human experience.”

“Being trans is not a disease or mental illness. Trans people are trans because gender diversity is a normal part of the human experience, as found in all Indigenous clan groups and tribes across the globe, including Australia — home to the oldest continuous culture on this planet.”

***

For many transgender activists and affirmative care practitioners even the assertion that a debate exists about the transitioning of minors is kryptonite. They insist the science on affirmation is settled, and to suggest otherwise sends a harmful, invalidating message to vulnerable children. 

That message was amplified in last year’s federal election campaign when, in an unsettling episode in Australian politics, the same vulnerable children found themselves news cycle fodder. Liberal candidate for Warringah, Katherine Deves, came under attack after past comments came to light in which she described transgender children as “surgically mutilated and sterilised.” (She apologised for the hurt her language had caused.) 

Scott Morrison backed Deves’ on the substance saying, “gender reversal surgery for young adolescents” was a “significant issue” about which parents were “very concerned”. His remark was at the very least careless with the facts. In Australia, the gender medicine fraternity recommends against genital sex-change surgery for under 18s. Yet while it is rare for minors to have their breasts removed, it’s not unheard of. In 2016 the Family Court approved a double mastectomy for a 15 year-old – Australia’s youngest reported case. In Sweden, a 2019 television report revealed that Stockholm’s prestigious Karolinska University hospital had carried out double mastectomies on children as young as 14. 

The former prime minister’s comments were widely interpreted as a “dog-whistle” to socially conservative working class voters. It’s a fair guess that youth gender transition is a more “significant issue”—  indeed, a pervasive, if muffled, anxiety — for the professional class, ever conscious of the long shadow of historical oppression of sexual minorities, and, like Yvette and Bublyk, exceedingly concerned to do right by their kids. As a clinician working on the frontline in one of Australia’s children’s hospital gender clinics told me, the families they encounter skew white, progressive and “middle to higher class.” (Children in state care are also over-represented in gender clinics around the world for reasons that are unclear.)

Gender-affirming treatment certainly wasn’t an option when Filipino migrant Hiram Cruz was growing up Melbourne’s west, sleeping on his belly in the hope his breasts might stop developing.

“That (getting treatment for dysphoria) was never going to happen,” the 32 year old transgender man explains. Cruz’s mother  — whom he loves deeply— is “a full-blown Jehovah’s (Witness).”

“She refused to believe that gays existed and to bring up transgender to her is foreign.”

Trans man Hiram Cruz Photo: David Geraghty

As recently as 10 years ago the battles of transgender people were foreign to most of the public. Even more foreign were the battles of children with gender dysphoria and the numbers seeking treatment, a trickle.

Professor Garry Warne, paediatric endocrinologist at Melbourne’s RCH, saw his first young transgender patient seeking hormonal treatment in 2003. When his colleague, paediatrician Michelle Telfer, took over the practice in 2012, establishing Australia’s first gender service, 18 children were referred for treatment. 

But within a few short years clinicians around the globe have borne witness to an earthquake in the annals of the young field of gender medicine. There has been “an upheaval in cultural narratives of sex and gender,” wrote Bernadette Wren, a former consultant clinical psychologist at the UK’s only public gender service for under 18s based at the Tavistock Clinic in London, in The London Review of Books. 

“A huge social change was underway, and we were on the frontline.”

Professor Pat McGorry, the driving force behind Australia’s early intervention services for youth mental health, had barely come across a gender-questioning young person in his consulting rooms until seven or 12 years ago. Nowadays, he says, “probably a significant number of young people that I get to see on the frontline of clinical care are gender diverse, it’s quite extraordinary.” He realised he had to learn about gender dysphoria. He read the medical literature. He also decided he’d “better go see” Telfer, at the RCH’s gender clinic to gain a deeper understanding of gender medicine.

By then, Telfer’s clinic was itself flooded with referrals. In 2015 — the year after a Time magazine cover heralded “The Transgender Tipping Point” — waiting lists at the RCH had blown out to 14 months. In 2018, new referrals to the clinic reached 268 – from 18 in 2012. The same year a survey of Australians in Years 10 to 12 found that 2.3 per cent identified as trans and “gender-diverse”; roughly 35,000 young people in that age bracket alone.

In 2021, when Victorian children confronted a second year of COVID lockdowns, referrals to the RCH’s gender clinic rose to more than 800. Last year that figure was over 1000.  

Similarly, Queensland’s children’s hospital gender service, which opened in 2017, had 241 new referrals two years later, and another 635 in 2021 — a rise of more than 160 per cent. 

It is the same story throughout the West; gender services struggling to keep pace with surging demand. 

Amid the turbulence, Australia emerged as a world leader in youth gender medicine. In 2018 Melbourne’s RCH published an affirmative care treatment protocol: the Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents. The Standards are a blueprint for gender clinics nationally, and lauded internationally; the prestigious journal The Lancet effectively declared them the gold standard in ameliorating the social harm dysphoric children commonly suffer.  

The judiciary has endorsed them too. Where 20 years ago families had to endure the stress and uncertainty of obtaining a judge’s authorisation for each phase of hormonal treatment — it was as if the child’s body was itself “on trial,” one mother said— successive court battles have removed the need for judicial oversight. Courts are only involved if there is a dispute between treating doctors or parents about the diagnosis, the treatment or the young person’s capacity to provide informed consent. Legal nuances exist in individual states, however. A recent Supreme Court decision in Queensland suggests that legally “competent” 16 and 17 year-olds can access cross-sex hormones even if both parents object.

One affirmative care therapist has seen the transformative impact of the decade of social change in the way clients talk about themselves. Even a few years ago young people were more tentative about revealing a transgender identity for fear they would not be believed or accepted, the therapist says. “But now, they have much more confidence, they say, ‘This is who I am.’”

Precisely how many Australian children are medically transitioned is unclear because the hospital gender clinics do not release comprehensive data. Telfer told the ABC’s Australian Story in May 2021 that more than 1000 children had received hormonal treatment at Melbourne’s RCH. In the same year, 402 minors from Australia’s five main hospital-based youth gender clinics were on either puberty blockers or opposite-sex hormones, according to figures obtained under Freedom of Information by NSW Labor politician Greg Donnelly, and compiled by Dianna Kenny, psychologist and academic. Kenny says the figures are likely an underestimate because they do not include drugs bought from outside hospital pharmacies. Nor do we know how many children with gender dysphoria access hormonal treatments from community or regional clinics. 

Some GPs also assess minors for medical transition. But in May, MDA National, one of four major medical indemnity providers, updated its policy to exclude cover for any claims arising from such assessments. As with the incendiary research from Westmead, it is a telling shift.

Despite — or perhaps because of — a decade of heady change, the affirmative care model now finds itself under tentative scrutiny in Australia, and serious challenge overseas.

And even some pioneers of affirmation are losing sleep for fear clinicians are transitioning minors and young people who aren’t, to quote Yvette, the mother we met early on, “100 percent trans.”

Affirmation under a cloud 

Four months after the Westmead report’s release, the governing body for psychiatrists, the Royal Australian and New Zealand College of Psychiatrists, released a long-awaited position statement on treating gender dysphoria. It stressed the importance of psychiatrists doing a comprehensive mental health assessment, fully exploring a person’s gender identity in the context of their lives. 

On the question of whether a gender-affirmative approach is appropriate for children and teenagers, the College highlighted the paucity of long-term research on outcomes. It also acknowledged the existence of “multiple perspectives and views”. This doesn’t sound earth-shattering, except that two years earlier the College explicitly endorsed the RCH’s affirmative treatment guideline for young people, including puberty blockers for eligible adolescents.

So the equivocation spoke volumes.

The following year, 2022, Sydney woman Jay Langadinos sued psychiatrist Patrick Toohey for allegedly green-lighting hormones and surgery -- each after a single consultation -- to help her embody the man she had first believed herself to be at age 17. (A Defence has been filed in the case.) By 22, Jay — she prefers to go by her first name— was on testosterone and had had her breasts and uterus removed. About four years later, while undergoing therapy with a new psychiatrist, Roberto D’Angelo, she came to realise “she should not have undergone” the interventions, according to her Statement of Claim filed in the NSW Supreme Court. Now, in her early 30s, the knowledge she can’t have children is “devastating.”

Of the decisions she made as a young adult, Jay says: “I wish at the time I knew how much I was hurting and why.”

Jay’s taking legal action for alleged negligence is novel, but stories of transition regret and bitterness towards the medical profession are becoming less so. A minority within a minority, a new crop of detransitioners and desisters — people who stop identifying as trans—are speaking out, and finding researchers prepared to document their long-neglected medical needs. 

One 22 year-old Melbourne woman, “Nic” — a pseudonym to protect her privacy— started testosterone at 18, stopped and now “re-identifies” as female. Before starting treatment at a gender service she had about 10 sessions with mental health clinicians spread over six months. In these sessions, she says, there was “no pushback whatsoever” to her assertion of trans identity.

The doctors had asked her to write a letter setting out why she wanted to transition. 

“Frankly, when I look at it now, it just reads deranged. Mentally disturbed, with all this internalised misogyny. Lots of red flags, put it that way.” 

She believes doctors had her pegged as “a textbook trans man.”

Melbourne woman “Nic,” a detransitioner. Photo: David David Geraghty

Both Nic and Jay tell of an unhappy home life, social isolation and grappling with same-sex attraction — backstories strikingly similar to that of the world’s most consequential detransitioner, Keira Bell, a British woman in her 20s. 

To affirmative care sceptics Bell is a hero who exposed the ideological capture of the medical and political establishment in the UK and beyond. These sceptics are a broad church of right-wing populists, gays (spearheaded by the UK-based LGB Alliance; notice the “Q’ and “T” have been dumped), radical feminists, parents, detransitioners, old-school transsexuals, clinicians — and Christians.

In 2022 Bell filed a statement in support of Australian Christian Lobby member Lyle Shelton, sued for vilification and discrimination over online posts in which he described two performers at a Drag Queen Story Time event in Brisbane as “dangerous role models.” (The case has been heard in Queensland’s Civil and Administrative Tribunal and a decision is pending.)

To affirmative care practitioners, Bell’s name arouses palpable resentment.

“She’s successfully managed to blame everyone else apart from herself for giving her what she admits that she deeply and vociferously wanted for several years,” says one clinician. “And she’s managed her grief by harnessing the support of those who would slam shut the therapeutic door on these young people out of fear, ignorance and prejudice.”

A former patient at the Tavistock’s gender service, Bell had been put on blockers at age 16 after what she claimed had been three “superficial” conversations with staff. She progressed to opposite-sex hormones and then to double mastectomy. By age 23 she had reverted to identifying as female and said she regretted her treatment.

“I was an unhappy girl who needed help,” Bell said. “Instead, I was treated like an experiment.”

Her case came to light just as the Tavistock — where referrals had shot up from about 250 children in 2011-12 to more than 5,000 a decade later — was coming under increased scrutiny over whistleblower claims that children were being fast-tracked to puberty blockers.  

Bell brought a case for judicial review of the Tavistock’s protocols, joined by an unnamed mother of a teenage autistic girl who was on the waiting list for treatment. In its ruling in December 2020, the UK High Court found children under the age of 16 considering gender reassignment were “unlikely” to be mature enough to give informed consent to puberty blockers. Even when minors were older than 16 doctors may need to ask the courts to authorise medical intervention, the judges said. Although the judgment was reversed on appeal the following September, with the court finding that it is for clinicians to decide if individual patients can give informed consent, the ground was shifting regardless.

Health authorities in several countries launched systematic reviews of the scientific literature on hormonal treatments for minors with gender dysphoria. They found the evidence that the benefits of these interventions outweighed the risks to be “very low,” inconclusive or missing.

Finland moved first. In 2020, in a change driven by adolescent psychiatrists at the helm of the country’s two hospital-based gender clinics for minors, psychological therapy replaced hormones as the first-line treatment for under 18s.

Sweden followed suit. The country had been reeling since a 2019 investigative TV documentary,  The Trans Train, aired doubts on the science behind paediatric transition and angry testimony from detransitioners. Last February the country’s National Board of Health and Welfare recommended limiting under-18s access to puberty blockers and opposite-sex hormones to “exceptional cases.”

Prestigious medical bodies or health authorities in France, Spain and Norway have urged caution on medically transitioning minors amid the unexplained rise in trans-identifying teens. 

Meanwhile, England’s National Health Service had initiated an independent review into the Tavistock gender service headed by prominent paediatrician Dr Hilary Cass. An interim report, released in February 2022, found the sharp increase in patients had overwhelmed clinicians and led to under-serviced children: as a single provider, the service was unsafe. 

Six months later the NHS announced the Tavistock clinic would close. New regional centres would be set up to ensure the “holistic needs” of vulnerable young patients were fully met.

As the news lit up social media, Australia’s trans health doctors argued that our child and adolescent gender services already aligned with Cass’ recommendations, which included embedding the services within mainstream paediatric health settings, initiating long-term research on patient outcomes, and decentralising care. All of which is true. But despite trans activists seeking to frame the Tavistock clinic’s arc as solely a failure in health administration and funding, the truth goes much farther. 

For one thing, the scandal surrounding the Tavistock is but one of several recent controversies in Britain about the influence of the transgender lobby. Indeed, the growing backlash against trans activism has earned the UK the derisive moniker, “TERF island.” (TERF stands for Trans-Exclusionary Radical Feminist; feminists who who believe womanhood is rooted in biology consider the term a slur.) 

An influential UK charity supporting trans children and their families, Mermaids, is under official inquiry after a series of revelations raised concerns about its operations. One revelation involved staff sending breast binders— a garment that flattens breasts to give females a more masculine appearance—  to children against their parents wishes.

Even the BBC came under investigation from its own podcasters about whether the broadcaster’s links — since severed— with activist group Stonewall undermined impartial reporting on debates about gender identity versus biological sex. There is an analogous controversy involving Australia’s ABC. The public broadcaster’s own Media Watch program has criticised the ABC’s partnership with Acon, an LGBTQ health organisation which, like Stonewall, measures the degree of trans inclusion in workplaces, on the grounds it could lead to “perceptions of bias in coverage, or bias itself.” Some months earlier Media Watch had pulled up the ABC for failing to report on the Tavistock’s closure “despite offering comprehensive coverage on other trans issues.” (The ABC insists its links with Acon do not influence editorial decisions.) 

Within weeks of the Tavistock closure announcement, a UK law firm said that at least 1,000 former patients would be joining a class action against the NHS, alleging “physical and psychological permanent scarring” from the negligent administration of puberty blockers. Such an action would constitute one of the biggest medical negligence lawsuits in history. There is good reason for scepticism: 1000 claimants would mean almost all children the service referred for puberty blockers in the past decade. It is hard to imagine they would all sue. 

That said, independent legal experts believe the Cass interim report could pave the way for claims against the Tavistock service for misdiagnosing patients as suffering from gender dysphoria and administering treatments with a shaky evidence base. 

On the heels of the UK story, The Australian reported that local law firm Gerard Malouf was exploring the prospect of a similar class-action here. The firm did not return calls. 

When in October the NHS released draft plans for its post-Tavistock gender services, the UK’s departure from the affirmation model, in both tone and substance, became apparent. In the draft plan, clinicians are told to be mindful that gender incongruence may be a “transient phase.” They must also address co-existing mental conditions: the Cass report had found that once children were assessed as suffering gender-related distress their other mental health issues— which may be the true source of the distress— went untreated.

Puberty blockers can only be administered if eligible children agree to be part of a formal research study — a requirement not in force in Australia. The plans give no guidance on whether older adolescents can continue to receive opposite-sex hormones.

And even affirmation through social transition — described in the Australian Standards as low risk and probably harmless — is discouraged for both children and teens because its psychological impacts are unknown.

Now Australia’s trans healthcare body, AusPATH, is expressing dismay about the UK’s policy turn. In a statement released in November, AusPATH said the post-Tavistock plans were likely to “exacerbate the higher rates of suicidality experienced by these young people in the context of ongoing pathologisation and discrimination.”  

But the UK’s newfound caution on youth gender transition should have come as no surprise to anyone who read Cass’s interim report. Besides condemning one gender service as dysfunctional, Cass broke the taboo around scrutiny of the affirmation model— chiefly, by naming the taboo. 

In her words: “There is lack of consensus and open discussion about the nature of gender dysphoria and therefore about the appropriate clinical response.”

***

For this piece, and others to come, state health departments and the children’s hospitals that are home to specialised gender units refused my requests to interview experts on the record. Queensland’s Children’s Hospital did not reply to my interview request. Numerous clinicians providing children with affirmative care spoke to me anonymously without their employer’s permission. Another clinician refused to be named unless they could see the entire piece first; I did not accede to the demand. 

***

Felix, Melanie Bublyk’s trans son, had aspired to work in the mining industry. But after obtaining a TAFE qualification in mining and drilling, he’s not so sure. He has a cleaning job at a Holiday Inn. And he’s been doing artwork, taking time to figure things out, hanging out with friends. Bublyk supports his decision, just as she supported his decision to transition as a 17 year-old. 

“Teenagers are still children but they’re also almost adults,” she reflects. “I think they need autonomy over their own bodies.

“Felix is moving on with life as a trans man and he is incredibly happy and content.” 

As for Mia— Yvette and John’s daughter— she continued with testosterone treatment after turning 18.

“But I’ve removed myself from it all,” her mother told me.  

Yvette is giving her daughter “space to work things out.” Let her lead her own life. 

“Growing up is about one of the hardest and most important things we do; we need to search for identity,” she reflects. “Kids need a subgroup that no parent can understand. It is the duty of the child to kick their parents in the face. What’s more hurtful to a parent than to say, ‘I’m not even the little girl you thought I was’? That even the name we picked with care was wrong?” 

Some nights she and John still retreat to their bedroom to cry, she told me.

In 2021, not long after Mia started testosterone, Yvette sent me a photograph of her. In it, I saw a young person with even, slightly androgynous features, intelligent eyes and a pensive smile. A pretty face. Mia had a new boyfriend, Yvette had told me; a fellow “cyber-geek,” supportive of her transitioning. 

The pair had moved in together and appeared deeply in love.

“She seems happy,” Yvette said. 

“Maybe this (transitioning) is right for her,” she said, during one of our several conversations over the years. And then, in a weary voice: “But what if I’m right?”