A QUESTION OF TRANSITION #2

Gender medicine's troubling past

This piece is part of a series on youth gender transition. You can read the first instalment, “Youth gender treatment under scrutiny” here: https://szegounplugged.substack.com/p/a-question-of-transition

Photo by Ben Wicks on Unsplash

At different times between 1975 and 1980, eight primary school-aged children were admitted to the psychiatric unit at Stubbs Terrace Hospital in Perth, Western Australia. The young patients were diagnosed as “gender disordered.”

This was a relatively enlightened era in gender medicine. Ten years earlier, for instance, two British doctors strapped a 17 year-old boy to a chair in a dark room and projected images of women’s clothing, simultaneously administering electric shocks to the youth’s body. It didn’t work: the patient continued to identify as female into adulthood when she became known as Carolyn Mercer. For many years, Mercer told the BBC, she had internalised society’s message that she was “dirty, wrong and evil.” 

The “treatment” methods were becoming less brutal at the time the eight Perth children were hospitalised, but the notion persisted that gender non-conformity was a sickness in need of a cure. In this way, the scientific establishment was instrumental in stigmatising sexual minorities and perpetuating the oppression that blighted their lives. 

Why am I telling you this?

Because we need to revisit the sorry past to fully understand “gender affirming care,” the dominant approach to treating gender dysphoria — a feeling of bodily distress — today. In large part, it’s a treatment model conceived as a response to the historical wrongs perpetrated in the name of medicine.

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In Perth, the children were hospitalised for between two and six months to “increase their social competence” and nurture their “unique personalities,” explained WA’s director of Child and Adolescent Psychiatry Services, Robert J. Kosky, in a 1987 report in The Medical Journal of Australia.

One nine year-old boy habitually wore high-heeled shoes, stockings, jewellery and make-up; another had been “attracted” to his older sister’s underwear since age two. Yet another “sat to micturate.” “Dorothy,” the one female patient, “vehemently” denied her sex and expressed disgust with her genitals. At her admission, she was “dressed in football clothes, including spiked football boots, and … carrying a football that her father had given her.”

At their initial interviews, the children expressed sadness and loneliness. Some had suicidal ideas. They were performing poorly at school. Teachers had remarked on the children’s cross-gender behaviour “negatively.”

While in hospital the children were encouraged by nursing staff to replace the “stereotyped” and “inappropriate” cross-gender behaviour with activities such as playing outside and making friends. Parents visited regularly and were likewise encouraged to join in the games. The children slept at home one night on the weekends. Parents also saw a psychiatrist or social worker once a week.

Hospital staff made no conscious attempt to replace the behaviour, Kosky explained, although the nurses witnessed “episodes of miserableness and anger” lasting weeks. Nonetheless, he noted with satisfaction, with the exception of one boy, removed from the hospital by his “sabotaging” mother, “cross-dressing ceased very quickly after admission to hospital.” Several months after discharge, one child resumed cross-dressing; he was readmitted to hospital for two weeks and again, the conduct ceased. 

Seen through a contemporary lens the events Kosky recounts have a tragic poignancy. Between the lines we glimpse the damage his well-intentioned treatment regime wrought on these children. They were all followed up post puberty. One of the males reported having been “actively homosexual” since age 14; but he did not believe he was truly homosexual, rather he’d been “programmed into homosexuality” by his mother. As to the other former inpatients, Kosky conceded they may not have been entirely forthcoming about their desires. Still, he reported that none of them “expressed homosexual feelings, was transvestite, or transsexual.”

So what did Kosky conclude from the study? He found that the children’s non-conforming behaviours were “relatively superficial” manifestations of the children’s “pathological” relationship with the parent of the opposite sex — the mother in all cases bar Dorothy’s.

“The parent needed companionship from the child, free of the anxiety that was created in them by gender differences.. He or she denied the child's biological sex, and encouraged their notions of opposite gender behaviours in their child.”

These interfamilial problems are “correctable,” Kosky wrote. 

Some parents, Kosky noted, had been advised by other professionals that there was “no hope”: their child would grow up transsexual or homosexual or, in one case, “would have to go to New York to have a sex-change operation.” But the good outcomes in this study suggested that “an overemphasis on a biological model of gender disorder may also lead to therapeutic pessimism.” 

Transition, in other words, was seen as a last resort for those beyond “hope” of cure. And from the late 60s until early this century even adults had their access to hormones and surgery tightly controlled by an authoritarian medical profession. 

Watch: archivist and trans woman Julie Peters talks about her childhood influences.

Trans people had to convince doctors that they felt “trapped in the wrong body,” writes Australian Catholic University professor Noah Riseman in a May 2022 paper on the history of transgender healthcare in Australia. They also had to conform to stereotypes of “white, middle-class respectability.”

Candidates for opposite-sex hormones and surgery were routinely denied treatment if they were not going to live as heterosexual post-transition, or were deemed unlikely to “pass” as the opposite sex, or worked in the sex industry. They were forced to submit to humiliating medical examinations, such as doctors measuring their genitals.

Psychiatrists, including Kosky, commonly believed that the distress an individual with gender incongruence experiences has its roots not in the “negative” responses or bigotry of others, but in personal problems; that these problems can be the underlying cause of the incongruence; that the incongruence is therefore “correctable,” and that correcting it so as to spare the individual a “sex-change operation,” is preferable.

The affirmation model — which arrived on the therapeutic scene around 10 years ago — flips each of these assumptions on its head.

The philosophy of affirmation sees gender distress not as a disorder that has its roots in a dysfunctional family or childhood trauma, but as an understandable response to the exclusion and harassment that trans people routinely confront. To feel incongruent with the sexed body is not regarded as the symptom of a “correctable”  psychological problem, but as an example of human diversity. Therefore, according to the affirmation philosophy, medical transition ought not be regarded as an option of last resort — even in the case of children. After all, the desire to embody the opposite sex is as natural as being gay; doctors should simply help trans people express their authentic selves. 

I’ll have more to say later in this series about the tenets of the affirmation model, how they came into being and why they’re increasingly in tension with new cultural realities. But it’s important to note that the medicalisation of gender distressed children, via puberty blockers and opposite-sex hormones, came decades before the affirmation philosophy was a thing.

In the same year that Kosky published his report in the medical journal, clinicians in The Netherlands were on the verge of a radical new experiment which they thought might help gender-distressed children blend in with society. This new treatment would no longer coax such children into suppressing their cross-sex behaviour.

Next up in A Question of Transition: the Dutch protocol — and why it’s being heavily revised.