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Submission to the RACP & the Federal Minister for Health
1
Gender Transitioning and Responsible Responses
1. Introduction
Recently there have been big changes across the world with respect to the gender
transitioning of children and adolescents. The American College of Paediatricians
has declared that ‘normalizing gender dysphoria is dangerous and unethical’ – a
view that is shared by the Association of American Physicians and Surgeons.1"2 In
June this year the Royal College of General Practitioners in the UK pointed out that
there is “a significant lack of evidence for treatments and interventions” and “a
significant lack of robust, comprehensive evidence around the outcomes, side effects
and unintended consequences of such treatments for people with gender dysphoria,
particularly children and young people”.3"
Speaking out or daring to question the lack of robust, scientific evidence for
transitioning regimes often comes at great personal cost for those who do so – they
are frequently vilified and some have been removed from their employment.4 5 6 This
lack of debate is due to the physicians and mental health workers “bowing to
pressure from ‘highly politicised’ transgender groups to affirm children’s beliefs that
they were born the wrong sex” according to Marcus Evans, a psychoanalyst and ex-
governor of the Tavistock and Portman NHS Foundation Trust.7
It is as though evidence-based medicine has been suspended when it comes to
gender dysphoria; objective criteria for diagnosis have been replaced by subjective
declarations on the part of the patient as justification for a range of puberty blockers
and hormonal interventions, which usually lead to surgical interventions. Gender
affirming interventions are now commencing at a very young age (as young as four
years of age). Surely this is a contravention of the primary ethos of medical practice
– ‘first, do no harm’ - not to mention acting against ‘the best interests of the child’
(UN Convention on the Rights of the Child)?
There are four stages involved in transitioning: social transitioning, puberty blockers,
hormone treatment and finally surgical intervention. Once social transitioning
begins the pressure to continue ‘all the way’, i.e., medical intervention, slowly builds
and dysphoria can become worse8. Those who transition have been shown to have
rates of suicidal ideation up to 22 times higher than the general population
according to a Canadian meta-study9.
There are a number of key elements to the issue of gender transition. They include -
a) lack of scientific diagnostic criteria for ‘transgender’ children and adolescents
b) the current trend to quickly diagnose and affirm children and adolescents as
transgender, rather than following the ‘wait and watch’ approach – there is
plenty of replicated research that shows 80-95% of children who experience
cross-sex identification in childhood eventually desist and identify with their
natal sex as adults10
c) similarly, the apparent dismissal of the fact that gender dysphoria for the
majority of children and adolescents is resolved through the natural process
of adolescent development
Submission to the RACP & the Federal Minister for Health
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d) lack of evidence that transitioning resolves mental health and wellbeing
issues in those who transition
e) the apparent adoption (if not promotion) of transgender ideology by
prominent medical institutions such as the Royal Children’s Hospital in
Melbourne
f) lack of research into the long-term impacts of interventions; children
undergoing transition interventions become medical patients for life, in the
absence of any reliable long-term data
g) lack of research on children and adolescents who later de-transition (to the
extent that it is possible); research shows that de-transitioning typically occurs
five years after transitioning11
h) lack of exploration of the social and cultural factors associated with gender
dysphoria (e.g., gender dysphoria as a culture-bound syndrome)
i) contravention of children’s rights - gender transitioning of children and
adolescents is arguably a breach of children’s rights under the UN
Convention on the Rights of the Child
j) conflation of the terms ‘sex’ and ‘gender’ and obfuscation as to their meaning.
Much of this can be traced back to post-modernist university ‘gender studies’,
which are based on ideology, not science nor sociology
k) lack of recognition that no-one is born transgender – that it is not possible to
be born into the ‘wrong’ body12 . In other words, gender dysphoria is
essentially a behavioral, socio-cultural construct with no scientific, biological
foundation.
2. How is gender dysphoria diagnosed?
Correspondence published in The Lancet, Vol. 392, 8 December 2018, in response to
an earlier Lancet editorial, noted that -
The health of transgender children is addressed with imprecise language and overplayed
empirical evidence in new Australian guidelines (Royal Children’s Hospital Melbourne.
‘Australian standards of care and treatment guidelines for trans and gender diverse children and
adolescents’) and in an Editorial (June 30, p 2576). Sex has a biological basis, whereas gender is
fundamentally a social expression. Thus, sex is not assigned— chromosomal sex is determined at
conception and immutable. A newborn’s phenotypic sex, established in utero, merely becomes
apparent after birth, with intersex being a rare exception.
Distress about gender identity must be taken seriously and support should be put in place for
these children and young people, but the impacts of powerful, innovative interventions should be
rigorously assessed. The evidence of medium-term benefit from hormonal treatment and puberty
blockers is based on weak follow-up studies. The guideline does not consider longer-term effects,
including the difficult issue of detransition. Patients need high quality research into the benefits
and harms of all psychological, medical, and surgical treatments, as well as so-called wait-and-
see strategies.
How is gender dysphoria diagnosed? The recommended questions are as follows,
according to the DSM-5 (American Psychiatric Association) -
In children, gender dysphoria diagnosis involves at least six* of the following and an associated
significant distress or impairment in function, lasting at least six months.
1. A strong desire to be of the other gender or an insistence that one is the other gender
2. A strong preference for wearing clothes typical of the opposite gender
Submission to the RACP & the Federal Minister for Health
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3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preference for the toys, games or activities stereotypically used or engaged in
by the other gender
5. A strong preference for playmates of the other gender
6. A strong rejection of toys, games and activities typical of one’s assigned gender
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the physical sex characteristics that match one’s experienced gender.
* for adolescents just two criteria will suffice
Surely no-one seriously considers these to be scientific diagnostic criteria? Well, yes,
unfortunately they do, but there has been great uncertainty as to how to classify this
ambiguous state of psycho-socio-cultural dis-ease. Until recently, gender dysphoria
was classified as a mental illness, but now it has its own classification along with the
unresolved ambiguity. In fact, gender dysphoria has all the characteristics of what is
called a ‘culture-bound syndrome’. The other factor to take into account with cases
of ‘gender dysphoria’ is that they actually may be instances of the more general
‘body dysphoria’13, and not gender related at all.
3. Gender dysphoria as a culture bound syndrome (GDS)
Gender Identity Dysphoria can be seen as a culture-bound syndrome.
What usually constitutes a culture bound syndrome is a dis-ease that cannot be
diagnosed by conventional Western medical examinations because of its social,
cultural and psychosomatic aspects – it is typically very difficult to reach a definitive
diagnosis.
Examples of culture-bound syndromes include susto, anorexia nervosa, repetitive
strain injury (RSI) and chronic fatigue syndrome (CFS). Rather than strictly medical
issues, they can be seen as adaptive responses to normatively ambiguous
social/cultural situations. I have conducted considerable research on susto and CFS.
Medical anthropology and sociology, which I taught at Curtin University, are often
relevant where there are ambiguities in health and illness diagnoses.
Gender Dysphoria Syndrome (GDS), as I prefer to call it, is a classic example of a
culture-bound syndrome. Such syndromes defy the assignment of conventional
explanations or meanings by both patients and physicians. There is a common
misconception that such maladies are not related to social and cultural contexts, but
their common element is anomie (Emile Durkheim) or alienation from the rest of
society. It is not as though the afflicted person wants to be in their situation, but
they feel they have no control or any other options (Holloway, 199414). In effect, they
are de-normalized in a social sense, but to attempt to make their deviance from
social norms somehow ‘normal’ would be a scientific deception.
The idea that trans identity is neurologically innate, set by laws of biology in utero, is one that
can only come from a perspective that is blind to historical and anthropological realities. In some
cultures, people who are outside the gender binary believe quite fully that they have chosen their
gender path. In some, it’s a choice made after the mid-point of one’s life, while in others, puberty
is when the issue is decided. What’s more important is that in different cultures and times, the
idea of gender identity and what it means to violate the gender binary and have a non-
conforming identity is different.
Submission to the RACP & the Federal Minister for Health
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If the transgender identity phenomenon was, as many people have said (ad nauseam with
arguments that sound way too much like people saying that men and women have different
brains that explain their culturally-assigned differences), genetic/epigenetic and determined
at/before birth, this would imply that the phenomenon of painful, debilitating dysphoria would
manifest in this way throughout history and in many cultures. It doesn’t. While there are gender
non-conforming people throughout history, the near-obsessive, anxiety and depression provoking,
dysphoric feeling that one’s primary or secondary sex characteristics are “wrong” for one’s brain
is a phenomenon that isn’t reflected in all history or cultures worldwide. It’s culturally specific.
A phenomenal amount of energy is devoted to telling people that their gender identity is brain-
based and innate, and that there are “male and female brains”.15
What is much more likely to be the case is that sexual ambiguities/anxieties/
psychopathologies may be due to modernity and the disjuncture between faster
physiological development compared with psychological/emotional development –
as pointed out, through extensive research, by Professor George Patton -
Many brain changes take place during adolescence. Some precede and initiate puberty. Others
continue for around a decade beyond. Yet gonadal hormones affect a wide range of neuronal
processes: neurogenesis, dendritic growth, synapse formation and elimination, apoptosis,
neuropeptide expression, and sensitivity of neurotransmitter receptors. Sex differences in brain
development during puberty might reflect the different effects of male and female gonadal
hormones.16
Gender dysphoria and gender identity issues are due to a combination of factors,
biological, social, cultural and economic, but to address these issues with medical
acquiescence to any expressed desire by children or adolescents for gender change is
at odds with what one has come to expect from the medical profession in terms of
their duty of care.
Recent research shows that adolescents who experience rapid onset gender
dysphoria are 83% female - 63% had been diagnosed with at least one pre-existing
mental health disorder or neurodevelopmental disability and their parents reported
further subjective declines in their teenager’s mental health (47%) and parent-child
relationships (57%) once they ‘came out’ as transgender. Transitioning is clearly not
the answer to these problems.17""
4. How does the medical profession deal with GDS overseas?
Data from the UK show a massive and continuing increase in children seeking
gender transition interventions - increasing among 13-year-olds by 30% in the year
to April 2019 to 331, with 14-year-olds increasing 25% to 511, and 11-year-olds by
28%, while the youngest patients were aged three 18 . Also, there has been a
continuing increase in numbers in Australia, as shown in Figure 1 below.
Meanwhile, in Sweden programs involving transitioning have come under ethical
scrutiny by the Swedish National Council on Medical Ethics (SMER) -
According to the definition used by the National Council for Social Affairs [broadly speaking, the
SE equivalent of NICE], gender dysphoria is a “condition of psychological suffering or reduced
functional ability in everyday life that is caused by the perception that one’s gender identity is
Submission to the RACP & the Federal Minister for Health
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not aligned with one’s registered sex”. In the past few years, the number of children and young
people who turn to health care providers for assessment and treatment of gender dysphoria has
increased dramatically. This increase is particularly large in girls. Similar developments can be
seen in many high-income countries. Assessment and treatment of gender dysphoria in children
and young people raises a number of difficult ethical questions. These concern the actual need,
benefits, risks, agency, integrity and equitable access to healthcare, and how gaps in knowledge
and understanding are addressed and managed. (Professor Asplund, Chair of The National
Council for Medical Ethics, 26 May 2019)
5. The impact of transgender ideology in Australia
Transgenderism is an ideology that has often been described as a cult, but perhaps it
is better described as the result of social contagion, as follows -
The explosion of cases of gender dysphoria, previously an exceedingly rare condition, over the
last few years has coincided with a meteoric increase in sympathetic attention to the topic in
regular and social media—thus suggesting social contagion. Parents whose children “come out”
as transgender when their friends do certainly agree with this explanation. (Robbins, 2019)19
Gender dysphoria and sexual identity issues need to be dealt with using rigorous
scientific evidence, not ideology. The RACP needs to thoroughly investigate these
issues – otherwise, there could be an explosion of gender dysphoria across Australia,
especially given recent legislative changes.
Figure 1. Referrals to Royal Children’s Hospital Melbourne over time
Data source: ABC News - https://www.abc.net.au/news/2018-09-20/childhood-demand-for-biological-sex-
change-surges-to-record/10240480
The increasing rate of transitioning among teenagers has been occurring in several
developed countries, such as the UK, the USA and some European countries, and
has been described as a ‘psychic epidemic’20.
So, what does the Australian and New Zealand Professional Association for
Transgender Health (ANZPATH) have to say about gender dysphoria? The Royal
Submission to the RACP & the Federal Minister for Health
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Children’s Hospital in Melbourne has released a publication, the principal author of
which is Dr. Michelle Telfer, the President of ANZPATH, titled Australian Standards
of Care and Treatment Guidelines For Trans and Gender Diverse Children and Adolescents.
These guidelines have many shortcomings, including -
a) The guidelines say, in relation to gender dysphoria, that "A study of the
mental health of trans young people living in Australia found very high rates
of ever being diagnosed with depression (74.6%), anxiety (72.2%),
posttraumatic stress disorder (25.1%), a personality disorder (20.1%),
psychosis (16.2%) or an eating disorder (22.7%). Furthermore 79.7% reported
ever self-harming and 48.1% ever attempting suicide" - but the proposed
treatment is 'psychological support' not assessment. Individuals who
transition have higher rates of autism spectrum traits than the general
population 21 and more psychiatric co-morbidities 22 . Further, and more
importantly, people who proceed with gender transition also have high rates
of depression, PTSD, suicidal thinking, et cetera. This is not mentioned in the
Royal Children’s Hospital document. There is also no mention of the
increasing phenomenon of de-transitioning.
b) The bias inherent in the guidelines is clear in the statement - "Other
psychiatric comorbidities such as depression, anxiety and psychosis may also
increase the complexity associated with treatment and intervention decisions
but should not necessarily prevent medical transition in adolescents with
gender dysphoria" (emphasis added).
Surely the opposite would be required, that is, treat the psychological factors
first, and then consider possible transition arrangements (if warranted). The
assumption/premise implied in this document is that supporting transition is
not only the best treatment but also the only treatment!
c) Australia’s leading medical association, the Royal Australasian College of
Physicians (RACP), which includes Australia’s paediatricians, does not
endorse it.
The RACP represents nearly 15,000 physicians and 6,530 trainee members across
Australia and New Zealand. The RACP position is as follows -
The College does not have a formal position statement on gender dysphoria. However, the College
supports access to best practice health care for individuals who identify as gender diverse or
transgender, and improved access to publicly funded specialist outpatient health care in both
paediatric and adult settings. (received from the RACP, email 8 March 2019, responding to
my email of 4 March 2019)
However, this leaves many unanswered questions, some of which I raised in my
original email to the RACP (4 March 2019). They include the following -
1. Is there a policy that includes consideration of the 'best interests of the child' (as
defined under the UN Convention on Rights of the Child)?
2. Does a child have to reach a certain age before gender change can be initiated by
anyone in the medical profession?
3. Does the Australasian Chapter on Sexual Health Medicine (AChSHM) or
the RACP treat gender dysphoria as a mental illness?
Submission to the RACP & the Federal Minister for Health
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4. As standard policy, is there any psychiatric assessment of children wishing to
undergo gender transition?
5. As standard policy, are there any social/psychological/cultural assessments of
parents or carers who support or request the gender transition of any children under
their care?
6. Is there any current research into gender dysphoria and its long-term psychological
effects in Australia? Including children who later decide they would like to reverse the
gender transition?
6. Is gender transitioning child abuse?
The impact of this ideologically driven practice on families is profound.
Normalization of puberty blockers and hormone treatments to solve complex issues
related to mental health and identity are placing families, children and adolescents
in difficult and painful situations without adequate guidance. The crises within
families and the silencing of dissent (‘no-platforming’) are now being documented in
Australia on the Women Speak Tasmania and the Trans Dissent Australia Facebook
sites. Academics and others who dare to challenge the transgender orthodoxy are
vilified.
The worst part of the unquestioning trend towards ‘gender affirmation’ along with
the subjective wishes of patients, is that evidence-based medicine appears to have
been suspended when it comes to treating a child or adolescent who presents as
gender non-conforming.
7. Conclusions
Australia seems to be moving in the direction of accepting gender transitions
without proper psychiatric evaluations under the guise of ‘affirmation’ responses,
whereas overseas countries, such as England, are moving in the other direction due
to –
(a) a lack of scientific evaluation of the benefits of transitioning children and the
long-term effects of the medications being used, and
(b) gender affirmation of young children and adolescents with medical,
hormonal and surgical interventions being seen as unethical and a form of child
abuse (even though unintentional)23.
While Australia hesitates to catch up with the rest of the world we recommend the
following –
1) Any physician or health-related staff involved in transitioning should be
made accountable for the long-term consequences of their actions.
2) We need a much more in-depth and consultative process before continuing
this social experiment of changing a child or adolescent’s gender.
3) Gender dysphoria should be recognized as a real health and wellbeing issue
and not passed off surreptitiously as having something to do with ‘equality’.
4) No changes in gender should be supported, let alone promoted, before a child
is at least 18 years of age. Below the age of 18 years the ‘best interests of the
child’ should be the paramount consideration for medical practitioners.
Submission to the RACP & the Federal Minister for Health
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5) Parents/carers should also be rigorously assessed when making decisions
about the gender transition of children and adolescents.
6) The difference between sex and gender needs to be fully understood by
medical practitioners and their patients. It should also be made clear to the
general public, so that the obfuscation of these two concepts by the trans
lobby is made apparent.
7) The Federal Government support for rebates on the medical interventions
involved in gender transition should be suspended until scientific research
has been conducted to resolve the issue of science versus ideology when it
comes to the medicalization of gender dysphoria.
8) The Federal Government should initiate a scientific inquiry into the long-term
consequences of gender transitioning through medical interventions.
9) The Federal Government should fully investigate the evidence base and
current research associated with gender transitioning in order to protect any
children and adolescents from further harm.
Geoff Holloway (Ph.D, sociology)
Hobart
9 August 2019
Note:
This submission is endorsed by:
! Dr. Sue Packer AM, Senior Australian of the Year
! Women Speak Tasmania
! United Tasmania Group (UTG)
cc: Federal Minister for Health, the Hon Greg Hunt MP
1"American College of Pediatricians, press release, 3 August 2016.
2 Cretella, M. A., Gender Dysphoria in Children and Suppression of Debate, Journal of American
Physicians and Surgeons, Volume 21, Number 2, Summer 2016.
3 The role of the GP in caring for gender-questioning and transgender patients, RCGP Position Statement,
June 2019.
4 Vigo, J., "Evil Womxn": The Silencing Of Biological Reality And The Technology Of Obfuscation,
Forbes, 26 October , 2018.
5 Entwhistle, K., An open letter to Dr Polly Carmichael from a former GIDS physcician, 18 July, 2019.
https://medium.com/@kirstyentwistle/an-open-letter-to-dr-polly-carmichael-from-a-former-gids-
clinician-53c541276b8d
6 MacGregor, I., Silencing and censorship in the trans rights debate, Tasmanian Times, 6 August 2018.
https://tasmaniantimes.com/2018/08/silencing-and-censorship-in-the-trans-rights-debate1-d1/
7 Doward, J., Politicised trans groups put children at risk, says expert, The Observer, 29 July 2019.
https://www.theguardian.com/society/2019/jul/27/trans-lobby-pressure-pushing-young-people-
to-transition?CMP=Share_iOSApp_Other&fbclid =IwAR28NMxBoNQJtI-r6Ke7yJFb_9rjk7sIB2Zn6_
RIyXuaIlRchD1Zd0Ln-lo
8 Marchiano, L., Outbreak: on Transgender Teens and Psychic Epidemics, Psychological Perspectives,
60:3, 345-366, DOI: 10.1080/00332925.2017.1350804, 2017.
9 Adams, N., Hitomi, M. & Moody, C. Varied Reports of Adult Transgender Suicidality: Synthesizing
and Describing the Peer-Reviewed and Gray Literature. Transgender Health. 2017 Apr 1;2(1):60-75.
10 Singal, J. What’s missing from the conversation about transgender kids?
https://www.thecut.com/2016/07/whats-missing-from-the-conversation-about-transgender-
kids.html quoted in L. Marchiano (see above)
Submission to the RACP & the Federal Minister for Health
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11 Stella, Cari, Female detransition and reidentification: Survey results and interpretation, 3 September
2016. https://guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-
reidentification-survey
12 Malone, W. J., Gender Dysphoria Overview, 18 June 2019. Institute of Medicine (US) Committee on
Understanding the Biology of Sex and Gender Differences. “Every Cell Has a Sex.” Exploring the
Biological Contributions to Human Health: Does Sex Matter?, U.S. National Library of Medicine, 1 Jan.
1970, www.ncbi.nlm.nih.gov/books/ NBK222291/.
13 Vigo, J., "Evil Womxn": The Silencing Of Biological Reality And The Technology Of Obfuscation,
Forbes, 26 October , 2018. https://www.forbes.com/sites/julianvigo/2018/10/26/evil-womxn-the-
silencing-of-biological-reality-and-the-technology-of-obfuscation/?fbclid=IwAR1C8Ccuuuia
NWy9amUTcb6iRVyd3V9wwjjxLoiC48Gu6xA3d4gP0a1wnU4#4c3522b718fd
14 Holloway, G., Susto and the Career Path of the Victim of an Industrial Accident: a Sociological Case
Study. Social Science and Medicine, 38, 7, 1994.
15 https://culturallyboundgender.wordpress.com/2013/03/03/the-concept-of-the-culture-bound-
syndrome
16 Patton, GC & Viner, R., Pubertal Transitions in Health, The Lancet, Vol. 369 March 31, 2007.
17 Littman, L. Parental reports of adolescents and young adults perceived to show signs of a rapid
onset of gender dysphoria, PLoS ONE (2018)
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330
18 Gilligan, A., Surge in girls switching gender, The Times, 30 June 2019,
https://www.thetimes.co.uk/article/surge-in-girls-switching-gender-c69nl57vt
19 Robbins, J. The Cracks in the Edifice of Transgender Totalitarianism, Public Discourse, 13 July 2019.
20 Marchiano, L., Outbreak: on Transgender Teens and Psychic Epidemics, Psychological Perspectives,
60:3, 345-366, DOI: 10.1080/00332925.2017.1350804, 2017."
21 Stagg SD, Vincent J., European Psychiatry. 2019 Jun 28; 61:17-22. doi: 10.1016/j.eurpsy.2019.06.003.
Autistic traits in individuals self-defining as transgender or nonbinary.
22 Saad TC1, Blackshaw BP2, Rodger D. Journal of Medical Ethics. 2019 Jun 22. pii: medethics-2019-
105611. doi: 10.1136/medethics-2019-105611. Hormone replacement therapy: informed consent
without assessment?
23 Brunskell Evans, H., Leeds Launch of The Declaration of Women’s Sex-based Rights – Speech by Dr
Heather Brunskell-Evans, 25 May 2019. http://www.heather-brunskell-evans.co.uk/body-
politics/leeds-launch-of-the-declaration-of-womens-sex-based-rights-speech-by-dr-heather-
brunskell-evans/?fbclid=IwAR1AyuJoxWtoC6pk_CDzo1kwBIEHYsUK06_ viT2vL30inaZB
wIcgu6q_RAI
