The Delusion of Certainty.

It beats doubt.

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.

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A paper published in the Medical Journal of Australia (MJA) nearly 40 years ago has moved from the shadows to the centre of the continuing debate over gender dysphoria. The paper, titled Gender-disordered children: does inpatient treatment help? [1], has apparently been used extensively in a variety of clinical, legal and academic settings to oppose what is called gender reassignment. As it happens, I met the author many years ago, during my first year of psychiatry training. He was then in his final year, after which he moved to child psychiatry on the far side of the city, so our paths almost never crossed. I’ve had no contact with him for decades and didn’t know of this paper until last week.

The paper describes eight cases of “gender-disturbed” children admitted to an in-patient unit for periods of up to six months. Recently, one of the children has claimed to have recognised herself, leading to a follow-up paper, also in the MJA [2], as well as TV items and newspaper reports. The original paper is descriptive only, a rather chatty style with no biological or statistical pretensions (for that reason alone, it would never be published these days). It gives brief details of 7 boys and one girl who expressed the wish to change gender and showed no interest in activities, clothing or friends of the biological sex. Crucially, the family dynamics were disturbed, with the same-sex parent functionally absent and the child having a close and binding relationship with the parent of the opposite sex who, in each case, was unstable in some form or other and emotionally dependent on the child.

The paper puts the case that the insecure parents were unwittingly projecting their secret wishes for a child of the same sex onto the child. When the child acted according to birth gender, the parent withdrew but when the child cross-dressed and adopted opposite behaviour, the parent responded with warmth and approval. That is, the development of cross-gender impulses, which began very early in all cases, was wholly a psychological matter of distorted relationships within the family. Treatment, which consisted of separating the child from the relationship, immersion in a “normal” atmosphere with no coercion, and therapy for the parents, was said to be successful in all cases but one which the mother terminated. There is no mention of medication in the original paper and no indication that transition to the opposite sex was ever considered. As the title of the paper asks, Does treatment help get the child on the conventional path?

This paper has apparently been cited many times in a variety of reviews, legal and political enquiries, custody and child abuse cases, etc. to support the claim that the cross-gender urge is a manifestaton of family psychopathology, and is readily rectified by unremarkable forms of management. In different places around the world, children have apparently been referred to protective services because of the concepts implied or stated. The recent paper, however, raises serious doubts about the integrity of the claims and the evidence on which they are based. After extensive investigation and review of hospital files and other documents, it seems there was considerable coercion applied to the children to involve them in “normal age-related activities,” including clothes and games, etc.. Transgressions of the ward rules were met with “time out” and intimidating interviews. More to the point, it didn’t work. According to the recent paper, all the child did was repress the urge and keep quiet about it.

Because of where I’ve worked, I’ve had little to do with people wishing to change sex. Several cases over the years were people already involved in a transition program interstate who were required to see a psychiatrist as part of the protocol. In each case, I took a normal history and went through the records but nothing much emerged: they were as normal as people who wanted to migrate or change to a different religion, so the sessions were little more than friendly chats. Others showed more or less disturbance, mostly social anxiety and depression related to self-esteem, and responded to routine management but they were clear that their lives would not be right while they remained trapped in the wrong body. However, all I had to do was provide reports, I wasn’t making the major decisions.

Readers will be aware of the heated debates going on around the world regarding the sudden surge in cases of young people who express dissatisfaction with their gender. What was once rare is increasingly common. For example, the Cass Report in the UK, issued last year (see Substack 25.06.2024) records a 100 fold increase in teenage girls in just ten years. Whatever the cause, we can be sure it’s not biological.

All this reminded me of matters from many years ago. In the years leading to the publication of the APA’s DSM-III, in 1980, there was a ferocious debate within American psychiatry as to whether homosexuality was a “mental disease” or not. An unstable alliance of psychoanalysts, biological psychiatrists and strict religious groups was pitted against the liberationist counter-culture, who eventually won the vote. In particular, one psychiatrist from New York was incensed by the change. Charles Socarides (1922-2005), a psychoanalyst, politician and relentless self-publicist published extensively in between running dozens of organisations and having five children from four marriages. Socarides was convinced homosexuality was a neurosis due to an overbearing mother and a weak or absent father. Over many years, he treated hundreds of homosexual men in psychoanalysis, claiming a “cure” rate of about 33% in converting them to heterosexuality. His eldest son, Richard (now aged 70) is openly gay and has had a successful career in business and advising politicians (including Bill Clinton). You’d have to ask what was driving his fascination with gay men but the world has moved on since then.

The second was the tragic case of David Reimer (1965-2004), a Canadian man who was raised as a girl after his penis was accidentally destroyed during a circumcision. He was the eldest of twin boys; his brother committed sucide two years before he did. As an infant, David was referred to John Money (1921-2006), a psychologist from Johns Hopkins Univeristy in Baltimore who had a growing reputation as a sexologist. Money was convinced the brain is sexually neutral and gender identity is wholly social in determination. He arranged for the child to have surgery, including castration and construction of female genitalia, and to be raised as a girl. After puberty, the boy was prescribed oestrogens which led to the development of breast tissue. However, by the age of 13, he was suicidally depressed so his parents revealed what had happened to him. He decided to transition to male, underwent further surgery and hormones, worked as a labourer and eventually married, adopting his wife’s three children. At age 38, everything fell apart and he took his life.

His story was publicised in Rolling Stone and eventually in a biography by John Colapinto [3, available in pdf on Internet Archive]. It is simply appalling, one unbelievable stuff-up after another, all powered along by the manipulative narcissism and grandiosity of the psychologist who built his “science of sexology” on the flimsy basis of conditioning theory and bullying defenceless patients. For years, the field of gender identity was dominated by Money’s notion of the mind as a “blank slate” waiting for society to write its instructions on. It’s now clear that it was all completely wrong. Intrauterine development of the brain, mammalian and otherwise, is heavily influenced by hormones, especially testosterone, but the details are definitely not clear. Since a male foetus is exposed to much higher levels of testosterone for much longer, we would expect the male brain to be different, and it is. My guess is that testosterone primes the brain to respond more strongly to the perception of threats and thence to dominance or submission, i.e. the differences are emotional, not cognitive, and not favourable to males. This is universal: practically every vertebrate known responds to threats in almost the same way, but that’s not the point. The point here is the certainty with which psychiatrists present theories or results that are later shown to be completely wrong. In brief, they don’t know what they’re talking about, but you’re not allowed to know that.

The author of the 1987 paper was totally committed to the idea that all mental disorder is psychological in origin. I’m surprised he didn’t throw in a few quotes from Freud although they would have been culled by his former professor and supervisor, who would have reviewed the paper. In turn, he was totally committed to the idea that all mental disorder is biological in origin. Neither of them, however, would have been able to point to a theory of mind or model of mental disorder that justified their beliefs. Intellectually, psychiatrists all exist in little worlds of their own. They feel comfortable with what they believe, even if they can’t actually say what it is but they never have to. There is an unspoken agreement not to pick holes in each other’s ideas, as in “People who live in glass houses shouldn’t throw stones.” At a psychiatric conference, for example, there will be lots of talks on psychiatry as biology; on how to get more people taking more drugs or more ECT; there will be talks on statistics and even some on social aspects of mental disorder, but there will never be any on the fundamental model of mental disorder on which all psychiatrists agree, just because there isn’t one. Anybody who brings up a mild critique of psychiatry will be quietly dismissed as “attention-seeking” while anybody with a serious critique will be dismissed as “antipsychiatry” [3]. Moreover, criticisms are never answered.

One recurring criticism is this: In the absence of any theory of normal psychosexual development, we cannot say what is normal and what pathological. We have no idea why, from very early in life, the majority of people are attracted to the opposite sex while a few aren’t. We don’t know. What’s the basis of sexual attraction anyway? In animals, most of it is due to pheromones activated by the weather, but ours is largely visual. Bearing in mind the power of sex in daily life, biological psychiatry has nothing worthwhile to say about it. Sigmund Freud dreamed up a fantasy about preverbal children lusting for their parents but there was no factual evidence to support it, and very considerable evidence to say he falsified his records to fit his theory [4]. For the rest, mainstream psychiatry’s views on sexuality are little more than a reflection of the prevailing social opinions, e.g. the bizarre theory of “masturbatory madness” [5]. In his masterly account of PTSD in the Vietnam and US Civil Wars, Eric Dean commented:

This impression of scientific certitude in the midst of substantial and potentially crippling problems is a tribute to the ability of psychologists and the psychiatric profession to acquire and wield power … the salient point is that the mental health professions have a track record of advancing diagnostic categories that lack clear underlying unity based on scientific evidence, but that, nonetheless, have the effect of responding to popular needs and aggrandizing the power and authority of mental health professionals [6, pp200-02].

That point is central to the critique of the 1987 paper: at the time, in the remote wastes of Western Australia’s capital (the most isolated capital in the world), the idea of sexual transition was socially unacceptable. How unacceptable varied from mild disdain to total abhorrence, and the psychiatry of the time was responding to that. How could this happen? The answer to that is my usual theme: there was nothing to stop them. I don’t mean nothing in terms of laws and so on, there certainly were plenty of laws regarding sexual behaviour but there was nothing in psychiatry, no theories to stop them. Thus, in a meeting of psychiatrists discussing sexuality, one of them could be a full-blown Freudian, babbling on about Oedipus and penis envy and all that; one a hard-core Skinnerian behaviorist, who believed in the “blank slate” notion and how all behaviour could be “shaped and maintained by contingent reinforcement” (rewards and punishments); one who believed it was all biological (but had no knowledge of how it might come to pass); one who thought is was all due to screwy parents and the child needed to be put in care; one who thought it was a social fad that should be indulged until it blows over; one who thought it was the work of the devil and trannies should beg divine forgiveness; one who thought the child was being deceitful and needed a firm guiding hand; and one who endorsed Thomas Szasz’s view that it’s all personal choice, do what you like but don’t do it in the street or you’ll scare the horses. That’s the level of science in psychiatry. Where the patient ended up was just a matter of chance.

And a final observation. I quickly skimmed the 1987 paper before reading the critique and found a number of contradictions, e.g. the claim that “there was no coercion”:

Age-appropriate behaviours were encouraged by the nursing staff members to replace the stereotyped inappropriate and isolating cross-gender behaviours. Children were encouraged to leave their rooms and join in play [1, p567].

Anybody who has worked in a psychiatry unit of any sort knows what that means: “You get that shirt off now and put this one on. And no standing in front of the mirror, boys don’t bother to comb their hair. OK, join in with the boys’ games. What? You heard me…” For a child separated from family and home, probably for the first time, that’s pretty scary. Did the author realise this? Probably not, his determination to show it’s all psychological and we’re doing the right thing meant those discrepancies just didn’t register. His beliefs shaped his observations. It’s called unconscious deadening, the delusion of certainty. Psychiatrists are very good at it.

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References:

1. Kosky RJ (1987). Gender-disordered children: does inpatient treatment help? Med J Aust, 146: 565-569.

2. McFadyen J et al (2025). An autoethnographic critique of a past report of inpatient psychiatric treatment for gender diverse children. Med J Aust 223: 359-364. doi: 10.5694/mja2.70037

3. Menkes, D, Dharmawardene, V, (2019). Anti-psychiatry in 2019, and why it matters. Australian and New Zealand Journal of Psychiatry 53: 921-922. https://doi.org/10.1177/0004867419868791

4. Masson JM (1984). The Assault on Truth: Freud’s suppression of the seduction theory. New York: Simon and Schuster.

5. Zachar P, Kendler KS (2023). Masturbatory insanity: the history of an idea, revisited. Psychological Medicine 53, 3777–3782. https://doi.org/10.1017/S0033291723001435

6. Dean ET. Shook over hell: Post-traumatic stress, Vietnam and the Civil War. Harvard: University Press, 1997.

PS: for anybody interested, the RANZCP has issued a clinical guideline on “the role of psychiatrists working with transgender and gender diverse people.” It’s a long, warm and cuddly tract which says nothing definitive for fear of upsetting one or other of the groups mentioned above.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.