The crisis consists precisely in the fact that the old is dying and the new cannot be born; in this interregnum a great variety of morbid symptoms appear – Antonio Gramsci (1891-1937)
The repercussions of the final report of the UK’s Cass Review into gender identity services (GIDS) and gender affirmation treatment (GAT) for young people echo around us. GAT means simply that to get sexual reassignment treatment, up to and including surgery, all the teenager has to say is “I want it.” Recently, an older colleague (they exist) said to me: “I thought we had enough trouble with ADHD and ASD being peddled by our profession, but this is so much more serious … It’s irreversible.”
My first post is here but as a reminder, the 4-year and multi-million pound Review said a very cautious approach is necessary in this remarkably uncertain field. Not least, it is uncertain because we don’t know the normal process of gender identity formation, let alone why it should change. The Review’s final report made numerous recommendations, largely centred around the idea that people under sixteen, or even older, can’t and shouldn’t make the irreversible decision to transition to the opposite gender without the most careful assessment and supervision.
In their equivalent of “Psychiatric Review,” the authors of a French language article took a similarly moderate position on what they (appropriately) call the Anguish of Puberty. It concluded:
The notion of gender has come to mean anything, either biological sex or sexuality, social roles or sexual attraction — even going as far as changing one’s gender according to seasons in the case of seasogender. Such vague definitions cannot be considered valid to make medical decisions.
The article makes a number of telling points: if gender is fluid, why provide irreversible “treatment” for something that its advocates claim is not even a disease? If sexual transition is “a journey of self-discovery,” shouldn’t ideology be kept separate from medicine? All perfectly reasonable comments, but in an article published on the Yale University Law School website, a group associated with the World Professional Association for Transgender Health (WPATH), mainly based in the US, is openly hostile to the Cass Review’s conclusions. They attacked the Review on numerous grounds, mainly that it’s bad science and bad sociology. However, their starting position is seriously biased as they are, as they point out, all totally committed to the idea that it is enough for a child or adolescent to say “I was born the wrong sex” for treatment to begin. This is precisely what the Cass Review questioned. There are many serious weaknesses in their case which, to mind, is self-contradictory. Also, these people are making lots of money out of providing “treatment” for a non-disease. Because it’s the US, there’s also a loud group of medical people on the other side arguing that the whole thing is a violation of God’s order and should be stopped, but we needn’t worry about them.
Here in Australia, a group called the National Association of Practising Psychiatrists organised a seminar last week, featuring Dr Cass as the main speaker. Unfortunately, it’s behind a pay wall but I’ll contact them to see if they’ll release it. Dr Cass took some of the WPATH criticism directly, showing that they had manipulated the material to produce the results they wanted or that various other complaints about the Review were simply false. Anybody who wants to criticise her final report on the basis of improper procedure or poor quality science is wasting their time. Most important, she emphasised that the availability of “treatment” has raced ahead of the science that justifies it, all made much worse by various gender identity clinics (GIDS) failing to follow the most basic medical processes, e.g. taking a proper history, talking to the family, excluding other causes for “gender dysphoria,” and so on. When this is done, most of the recent massive surge of teenagers who have decided they are boys trapped in a female body show the same levels of social and mental disturbance as teenagers who attend child and adolescent clinics for different reasons.
Dr Cass described how her committee approached the Tavistock Clinic in London, which had long had the only GIDS for young people, to ask for their follow-up figures: in simple terms, what happens to your patients once they reach adulthood? One psychiatrist there had assessed most of the adults who had completed sexual reassignment but who then wanted to revert to their sex of birth (actually, it’s too late, you can’t). The committee asked to audit his files and his figures as an essential part of their study, but he refused to cooperate. That’s outrageous and the immediate reaction is: What’s he hiding? In fact, we already know: early use of puberty blockers and hormones doesn’t lead to any improvement in mental health in what is a pretty disturbed and unhappy group. Which raises the question: Why has the number of referrals of teenagers requesting sex change gone up over 100 times (10,000%) in 10 years, with the case profile changing from adult males with a 20 year history, to young teenage girls (median age 14) who decided a few months ago? The report doesn’t attempt to answer those types of questions.
While Dr Cass was studiously neutral in her presentation, it is quite clear that what should be a scientific question has been subverted by political activism. The Cass Review can’t be criticised on the basis of science, especially when many of the critics are making heaps of money out of it while the rest have strongly-held ideological/political positions.
After Dr Cass, there were three other speakers to discuss different aspects of the whole transgender thing. First was Prof. Patrick Parkinson, formerly Dean of the Law School, University of Queensland (the university ranks about No. 45 in the world). He has practised in the field of family law and child protection for decades, and opened by asking: “Will we see a tsunami of litigation relating to gender reassignment?” He pointed out that most teenagers receiving puberty blockers and hormones are being treated outside the approved guidelines for these drugs. This means that if anything goes wrong later (which could be very much later), there will be lots of personal injury lawyers hanging around, eager to sue the doctors involved. The risks, he pointed out, are enormous, verging on existential:
Family law cases are extremely complex … We need a national expert panel to approve puberty blockers and cross-sex hormones. This is what extreme caution looks like … Without it, litigation will get worse, it could destroy the professional reputations of practitioners, of hospitals and the professional medical colleges … but the colleges are refusing to get involved.
He didn’t mention the devastating effect a flood of these claims would have on the medical defence insurers, without which nobody can practise. Just in case anybody hadn’t got the message, he listed seven possible bases of legal action:
1. Failure by practitioners to apply approved diagnostic criteria. A child saying “I want to change” isn’t good enough.
2. Failure to consider or exclude other explanations of gender incongruence (of which the most common is the passing phase called ‘puberty’).
3. Failure to take a history from both parents. Believe it or not, this happens.
4. Failure to consider alternative treatment options. “Gender affirmation” says “There are no alternatives.” There are always alternatives.
5. Unlawful treatment of non-binary adolescents (current treatment is unlawful in many parts of the world as it doesn’t treat a disorder; and as it will have irreversible effects on fertility, it qualifies as a mutilating operation, which is forbidden by UN conventions)
6. Failure to assess whether minors have legal competence to make these decisions (in law, they don’t).
7. Failure to obtain proper informed consent. Forget it, there’s no such thing as informed consent in this type of field.
Regrettably, when the emphasis is on “child-driven decision-making,” these crucial steps are routinely ignored. He concluded by saying: “I have been personally stunned to hear senior medical practitioners say: ‘There is no alternative (to reassignment), there is no other explanation for gender incongruence.’ Their very rigid and fixed views are not borne out by the evidence” (he emphasised that court decisions are based only on the evidence, not on opinions; opinions formed without following due process means the practitioners are sunk. Anybody who doubts this should look at the inglorious end of Melbourne’s Prof. Graham Burrows; note that Burrows’ Wikipedia entry has disappeared).
Well, after that jolly presentation, everybody involved in this business should be running for cover. As a health practitioner, the last thing you want is a bunch of salivating lawyers on your case but, he made clear, because of sloppy standards, it’s going to happen. The next speaker was Dr Alison Clayton, a psychiatrist and PhD student in Melbourne University’s Dept of History and Philosophy of Science. Dr Clayton gave a brief but interesting review of the historical progress of medical innovations, from “promising reports” to oblivion, when everybody pretends they had nothing to do with it (the primary source is at [1]). You can believe that the history of psychiatry is littered with such disasters, but medical students and trainees in psychiatry are not told about them. Their eyes sparkling with excitement, psychiatrists only look forward; they never look back at the wreckage they have left.
In the next talk, entitled “Gender, Medicine and Politics,” Dr Andrew Amos, of Townsville, who has published on the topic of gender affirmation treatment (GAT) [2], talked about the refusal of Australian medical authorities, including the RANZCP, to consider the implications of the Cass Review in any meaningful way. In GAT, we see that the medical model of treatment has been dumped in favour of promoting a political agenda: “Gender affirmation treatment is the triumph of politics over medicine.” Practitioners ignore the harmful side effects of GAT on the basis that the right of (often very young) patients to self-determination is more important than the quite horrendous risks and unknown long-term complications of embarking on an irreversible course of treatment for something that hasn’t even been shown to be a “disease state.” The rights of the group of people seeking gender reassignment trump those of the individuals involved. Anybody involved in GAT accepts the essential belief that gender identity is a healthy variant of normal and is never the result of any form of mental trouble. Doctors who accept that there is no mental disorder involved in the decision to change one’s gender are, he believes, incapable of acting as ethical or competent practitioners.
He concluded by mentioning that he has spoken to members of the Board of RANZCP and confirmed that they “… have refused to take any position on the Cass Review … some have offered the fig leaf that the Review is not relevant to Australian and New Zealand, but it’s clear that this is a lie.” Moreover, Australian medical authorities have refused to consider a similar review in this country, the only conclusion being that it would harm their agenda. Needless to say, Dr Amos has copped some faeces as a result of his firm views.
The last talk was by Prof. Dianna Kenny, clinical psychologist from University of Sydney, on “Psychotherapy for transgender-declaring adolescents.” She pointed out (again) the high incidence of mental problems in these teenagers which are frequently “ignored and untreated” in GAT, so that nobody ever works out what came first, the mental problems or the wish to change sex. She briefly described several cases where, for clear psychodynamic (non-biological) reasons, children felt they needed to change gender. Most teenagers presenting at these clinics, she said, have no sexual experience and express revulsion at the idea of penetrative sex, although the thought that, as transgender adults, they will still be expected to perform sexually hasn’t occurred to them: “Sexual development poses a threat to some young people as it signifies approaching adulthood, the demands of which they feel ill-equipped to manage.” Flight to transgender seems one way out of the mess, except all too often, it leads to a much bigger mess.
She took the strongest line, urging governments to take concrete steps “…to reduce the numbers of young people who have fallen prey to this latest psychic pandemic.” This would include immediate cessation of all medical treatment of people under 18 while society (prodded by government) stops all publicity of the idea that gender is a matter of choice, including a return to gendered language and banning the expression “non-binary.” She believes children should not be able to change their sex at will and must be taught that puberty is a natural biological process through which all humans must pass. She urged societal intervention on the basis that external pressures are driving this “pandemic”:
A sane society, governed by sane politicians, and assisted by sane public health officials, will have made that decision a priori, i.e. no medicalised gender treatment for minors. This will end the transgender pandemic ... The current approach, medical intervention without theory or evidence, has proved a dangerous, if not disastrous, road.
Sane politicians? Good luck with that one but remember, it isn’t a pandemic. It’s not even an epidemic. It’s a fad, and it’s a fad affecting a very specific group in the community: young (median age 14), lonely, unhappy, insecure, mistrustful and resentful girls with terrible self-esteem; who have a high incidence of adverse childhood experiences such as broken families, various sorts of deprivations, and emotional, physical and sexual abuse; who show high levels of anxiety and depression; who are doing poorly at school; who do not see themselves functioning as independent, sexual women; and who are only distinguished from other teenagers attending mental health services on the basis that, by watching social media over the past few months or a year, they have decided they need to be reborn as boys so “life is beautiful all the time” (that line comes from this, which gave responsible people the absolute shits). And, according to the GAT activists, it’s not an illness in any sense, it’s a perfectly healthy normal variant. So if it's not an illness, why are medical/health services involved? No answer.
My older colleague has often said: "I look at psychiatry and despair." In his sonnet (which I think is the greatest poem in the English language), Shelley’s Ozymandias says: "Look on my works, ye Mighty, and despair!” But his works have all gone:
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.”
We have an “epidemic” of bipolar disorder [3]; 15% of boys in the US are diagnosed “ADHD”; we have an “epidemic” of so-called autism; and now whoever is left wants to be something else. If this is psychiatry, do we need it, or must this frenzy of socially-driven self-diagnosis lead to the entire psychiatric industry falling into discredit, its ‘colossal wreck’ surrounded by an intellectual desert? We’re actually halfway there. So what’s going on, why is this happening? There are two reasons. First, over twelve years ago [4], I set out my case that mainstream psychiatry is undertaking a massive program of taking people with personality disorder, for which psychiatry has no treatment, and re-diagnosing them as suffering from “mental illnesses” which, of course, require life-long drugs and lots of valuable appointments. And pensions, of course, but psychiatrists don’t care about that.
The second reason is that psychiatry dithers on the sidelines, wringing its collective hands because it doesn’t have the intellectual resources or moral courage to stand up and pronounce firmly: “This is all bullshit.” The reason it doesn’t do that is because mainstream psychiatrists don’t have a theory of personality or a model of personality disorder that allows them to draw a clear line between genuine mental problems and transient social fads.
My view is that if you’re not on the edge, you’re taking up too much space. Let’s move to the edge:
The massive surge of gender identity disturbances is nothing more than a socially-determined fad affecting a small, isolated group of young people with primary personality disturbances (including anxiety) and secondary depression, all related to their unhappy lives, with no biological disturbance whatsoever, who are preyed upon by a sophisticated group of media-wise, sociopolitical activists who benefit from recruiting converts to their cause.
That is, this business has all the makings of a cult. Anybody who disagrees can send me an essay proving that gender identity disturbance is not a primary personality disorder (Spoiler alert: it can’t be done. See above “lack of model”).
This is what Gramsci meant when he said “The old is dying and the new cannot be born.” The old biological psychiatry, built on unfounded opinions held in place by professorial bluster, controls the narrative with a grip of steel, preventing the emergence of modern theories of mind and models of mental disorder. In the absence of direction from psychiatry’s self-appointed “key opinion leaders,” morbid symptoms such as “gender identity disturbances” and all the rest of the pseudoscience, appear and proliferate just because where science is blighted, politics grows.
If, by their insipid fear of upsetting influential groups and driving away custom, the psychiatric profession refuses to take a firm stand on this question, the institution of psychiatry itself could be dragged into a legal and moral morass. It’s one thing to say of an unhappy person “He’s bipolar” when he’s actually seriously anxious, knowing that your colleagues will all swear an oath of support in court, and something else again to stand back while a child destroys its sexuality in the misguided belief that s/he is the victim of a cosmic error that just needs some puberty blockers, hormones and a surgical snip and tuck to correct. No, it won’t. The whole thing is bullshit.
By its inability to show intellectual leadership, psychiatry stands condemned. And the reason it can’t show intellectual leadership is because, at the heart of the entire psychiatric enterprise, where there should be an articulated model of mental disorder, there is only the deathly silence of an intellectual vacuum. Eventually, society will wake up to this and then it will really hit the fan. Good. Bring it on. But I’m sorry for all the kids whose lives will be wrecked, and sorry for the kids in Darfur and Gaza and Ukraine whose lives are being destroyed while psychiatry refuses to take a stand for fear of losing influence and money by upsetting powerful constituencies.
References:
1. McKinley JB (1981). From “Promising Report” to “Standard Procedure” : Seven Stages in the Career of a Medical Innovation. Milbank Memorial Fund Quarterly/Health and Society, 59 (3): 374-411. Available at:
2. Halasz G, Amos A (2023). Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice. Australasian Psychiatry 32. https://doi.org/10.1177/10398562231211130
3. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.
4. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.
I’ve been waiting for you to turn your attention to this. Any psychiatrist who approved gender affirming surgical mutilation for any child who doesn’t have the requisite legal capacity to sign up for a game of touch football, let alone cut their genitals off, should be in prison.
This is another tragic case of modern medicine profiting from social dis-function and vulnerable patients. It needs to be stopped urgently. Civil lawsuits are too soft. These doctors and those aiding them need to be criminally prosecuted.
At first this may appear as modern medicine running off the rails however it fits in with the mindset of treating symptoms and not causes and ignoring adverse events.
Something drastic needs to be done to get modern doctors to respect the doctrines of: 'first do no harm' and 'informed consent' (although not possible for minors).