Welcome to Quadrant Online | Login/ Register Cart (0) $0 View Cart
Menu
May 10th 2017 print

John Whitehall

Childhood Gender Dysphoria and the Law

Judges seem untroubled by the contradiction inherent in a diagnosis that has become rather fashionable of late, 'gender dysphoria'. On the one hand the condition is described as a psychiatric illness, yet the purported remedies of hormones and surgery are entirely physical

facelessChildhood gender dysphoria may be defined as distress due to conflict between the physical manifestations of gender in the body and their perception in the mind of a child or adolescent. The body reveals one sex, the mind feels the other.

This conflict between matter and mind can be as destructive as any other confusional state and deserves our compassion. Disturbingly, special clinics in capital cities in Australia are now reporting hundreds of new cases seeking attention each year. This contrasts, dramatically, with a straw poll I have undertaken of twenty-eight paediatricians with a cumulative experience of 931 years. This poll revealed only ten cases: eight associated with mental illness, two with sexual abuse. Protestations by a child that it belonged to the opposite sex used to be a warning sign of sexual abuse.

Given the increasing prevalence, the perturbation to family life as well as the mind of the child, and the possibility of prolonged therapy, the importance of gender dysphoria now rivals that of anorexia nervosa with its incongruity between bodily reality and mental perception (the body is thin but is imagined to be fat).

Fundamental differences exist, however, between the medical and societal managements of anorexia and gender dysphoria. In anorexia, management seeks to reduce the mindset, not substantiate it. No medical authority would augment weight loss with diet pills and a gastric band. No media would portray anorexia as heroic. No legislature would forbid therapies that did not affirm the delusion. No court would praise the courage of the child in refusing food, and no court would consider being relieved of a protective role. But, with regard to gender dysphoria, these are the kinds of things that are happening.

This article will consider three matters: First, the treatment regime for childhood gender dysphoria; second, Family Court of Australia decisions regarding childhood gender dysphoria; third, research that indicates medical treatment for gender dysphoria may result in permanent changes in the brain.

Treatment for childhood gender dysphoria

International consensus declares that up to 90 per cent of children who question their sexual identity will orientate to their natal sex by puberty[1]. Particular difficulties, however, may occur when there are associated mental disorders such as autism spectrum and defiant disorders, and depression. Dr Kenneth Zucker of Canada would also warn of “environmental” factors including family influences, especially maternal, that predispose to gender dysphoria.

Given this likelihood of recovery, international opinion warns against “parental commitment” of the child to full “social transitioning”. This is contrary to examples on television in which young children are renamed, re-clothed, re-declared and re-enrolled in schools as the opposite sex. This transitioning should be avoided because it will make it difficult for the child to return to its natal sex at puberty. Worse, the psychological imprinting of being raised as the opposite sex may lead to lasting confusion. Worse still, the child may progress to medical intervention from which there may be no return.

This essay appears in the May edition of Quadrant.
Click here to subscribe

If the child is experiencing gender confusion, punitive measures should be avoided but kindly restrictions are in order as, for example, to where cross-sex clothing might be worn. The best approach would be “watchful waiting”. The worst would be to allow the child to become a poster exhibit for the school and the media.

Childhood is the time of development of identity, and exploration is inherent. Puberty is the time of physical development for procreation; adolescence, for gaining maturity to raise offspring. The Bible explains, “When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.” In that sense, puberty orientates the child towards the binary function of reproduction and rearing of the species.

Some therapists conclude that international reassurances do not pertain to the individual under their care and enter the child onto the pathway of medical therapy for gender dysphoria. This pathway is known as the “Dutch protocol” because it evolved from the Centre of Expertise on Gender Dysphoria in Amsterdam. The protocol became basic, in 2011, to one of the Standards of Care of the World Professional Association for Transgender Health.[2] It comprises:

Stage 1 therapy. Puberty is initiated by a biological clock deep in the brain and involves a cascade of chemical messengers that travel to the gonads to cause them to release hormones that evoke secondary sex characteristics and to prepare for procreation using organs laid down before birth. Not surprisingly, there are many checks and balances in this “multi-variant closed loop control system”. Chaos from an inserted spanner could be expected.

In 1971 one of the chemical messengers was identified and then manufactured in a laboratory. As it stimulated the release of hormones from the pituitary gland that went on to stimulate the gonads, it was called gonadotrophin-releasing hormone (GnRH). Researchers found that GnRH was secreted onto the pituitary gland in pulses, every hour or so, as if the pituitary needed a period of rest before releasing its next burst of gonad-stimulating hormones.

Cleverly, scientists altered the structure of the GnRH molecule so it would stimulate the pituitary gland but would not “let go” of its docking receptor. This “agonist”, or sustained stimulating effect, resulted in an immediate surge of pituitary hormones followed by inactivity for as long as the agonist lasted. Varieties of “GnRH agonists” were developed to last many weeks after injection and were employed to block release of sex hormones from the gonads in medical conditions in men and women.

It was also found that agonists would block the development of puberty if it was occurring too early. Subsequently, it seemed a good idea to employ blockers in cases of gender dysphoria, to give “more time” for the child to think about transitioning, and to postpone the appearance of secondary sex characteristics which might be upsetting. Such use was suggested to be delayed until the age of twelve or, at least, until the earliest stages of puberty had emerged.

The main side-effects were declared to be reduction in bone density, which would recover when sex hormones were applied. The psychological effect of delaying puberty while peers were maturing was also considered and would become the basis for calls for giving sex hormones at increasingly younger ages.

In all Family Court considerations of blockers since 2004, only once was mentioned an effect on “cognitive ability and mood”. Otherwise, blockers were declared “safe and entirely reversible” and, on that basis, their administration could be safely left to children, parents, guardians and therapists.

Stage 2 therapy involves administration of hormones of the opposite sex (testosterone and oestrogens) to evoke their external characteristics, advisably not before sixteen years of age. Such hormones would need to be continued for as long as the patient wanted to remain transgender, presumably for life. Side effects included metabolic, vascular, bone and emotional problems which would need sustained medical supervision. In some Family Court cases, the effects were declared to be “partially reversible”, though how long it would take to result in chemical castration was unknown. An effect on the structure of the brain was never mentioned. Ironically, some deliberations listed psychological complications of depression, anger and instability which the use of hormones was intended to reduce.

Stage 3 therapy would involve irreversible surgery, not usually performed under the age of eighteen.

Decisions of the Family Court of Australia on gender dysphoria.

Review of Family Court decisions published online by the Australasian Legal Information Institute under the generic term “gender dysphoria” reveals almost seventy cases since 2004. Correcting for multiple appearances and removing cases of physical intersex now known as “disorders of sexual development” leaves fifty-six children with incongruity between natal sex and current feelings. Physical disorders should be removed because they are as irrelevant to psychological gender dysphoria as congenital abnormalities of the bowel are to anorexia nervosa.

Most of the fifty-six children went before the court for authorisation to consent to receive cross-sex hormones. In the earliest cases, some sought blockers. Five were authorised for bilateral mastectomy.

The review reveals a soaring incidence: from one case a year in 2004 and 2007, to two in 2010 and 2011, to five in 2013, then back to three in 2014, followed by eighteen in 2015 and twenty-two in 2016. So far there have been two in 2017. Natal females outnumber males thirty-four to twenty-two.

The summaries do not detail medical features, but many may be discerned. For example, in twenty-five of thirty-nine cases in which family arrangements can be discerned, dysphoric children live with single parents or in foster care[3] and only fourteen with both parents.

thirty-eight children are reported to have revealed gender dysphoria before the age of seven. Many are claimed to have demonstrated it from the earliest years. One parent declared an infant had identified with its opposite sex at the age of nine months, apparently not challenging the credulity of the court.

In twenty-eight of the fifty-six children, mental co-morbidities are emphasised. These include Autism Spectrum Disorder (six), major depression, incapacitating anxiety, oppositional defiance, attention deficit or hyperactivity, and intellectual delay. Though many of these major disorders were revealed in earliest years before or in parallel with gender dysphoria, therapists claimed gender dysphoria as the cause and its treatment as the primary solution.

In fifteen summaries, including the last one available in 2017, the safety and reversibility of blockers are emphasised. None refers to effects of cross-sex hormones on the structure of the brain.

In forty-one cases which reported on the competency of the child to understand the treatment to be received, eleven children were acknowledged to be incompetent, and authority to consent for treatment was extended to parents and guardians, as guided by therapists. Many of those with mental co-morbidities were considered to possess “Gillick competency”, as discussed below. Such illnesses were apparently presumed not to affect understanding or motivation.

Of the five authorised to consent to mastectomy, the first was in 2009, involving a sixteen-year-old who had been on blockers for five years and cross-sex hormones for one year. The next was in 2015, a sixteen-year-old on cross-sex hormones for a year. Of those in 2016, one was fifteen and on blockers for nearly two years and cross-sex hormones for eight months; one was seventeen and appears to have had no previous hormonal intervention; and one was fifteen and on blockers for almost one and a half years. The possibility that extended exposure of the brain to blockers and cross-sex hormones might reduce the capacity for informed consent was never discussed.

Gillick competency and re Marion.

Fundamental to understanding the Family Court’s summaries is the concept of Gillick competency, and the Australian case known as re Marion in which parents sought permission to consent on behalf of a retarded daughter for sterilisation to minimise the effects of menstruation and the possibility of pregnancy.

In considering whether Marion had the capacity to decide for herself, the Australian court accepted the precedent from the House of Lords regarding a Mrs Victoria Gillick who contested, unsuccessfully, that children under sixteen were not competent to consent for contraception therapy[4]. The English court decided that if a child possessed “sufficient understanding and intelligence to … understand fully what is imposed”, the child could consent to medical treatment. This capacity became known as Gillick competency[5].

In 1992, in re Marion, the Australian court followed the House of Lords, declaring “This [Gillick] approach though lacking the certainty of a fixed age rule accords with experience and psychology” and “should be followed … as part of the common law”[6].

Accordingly, if the child was “Gillick competent”, court authorisation would not be needed for medical interventions for conditions that involved “malfunction or disease” and were given “for the traditional medical purpose of preserving life”.

If these traditional reasons for medical intervention were not obvious, and the child was Gillick incompetent, the authority of the court would be needed in “special cases” involving “invasive, irreversible and major [surgery]” where there was a significant risk of making a wrong decision and the effects of that decision were “grave”. If the intended intervention was “non-therapeutic” and the child Gillick incompetent, neither parents, guardians or the court had the power to consent.

Re Marion emphasised the need for the protective role of the court, as averred in re Jane, that “the consequences of a finding that the court’s consent is unnecessary are far reaching both for parents and for children. For example, such a principle might be used to justify parental consent to the surgical removal of a girl’s clitoris for religious reasons.”[7] Re Marion went further, warning against unqualified trust in the medical profession which, “Like all professions … has members who are not prepared to live up to its professional standards of ethics … Further, it is also possible that members of that profession may form sincere but misguided views about the appropriate steps to be taken.”

The High Court considerations in re Marion have been like a stake in the ground to which subsequent courts have been tied with a short leash. As popular opinion demands the acceptance of gender dysphoria as part of rainbow normality and not a disorder, courts appear to be struggling to be free from the restrictions of such words as malfunction, disease, therapeutic, necessary, best interests, competency and responsibility. But what words in the English language can be used to define an entity as “normal” when it requires massive medical, and even surgical intervention, to confirm and maintain? And “necessary” when there is evidence the child will grow out of it?

In the end, the possibility of freedom for the court emerged: parliament could pass a law to extricate it from the whole business. Politicians could provide the bowl and the water for the washing of hands.

And, as the crowd encouraged Pontius Pilate, a petition launched in 2016 by Georgie Stone has garnered 15,659 signatures to “Remove Family Court of Australia from Medical Decisions for Trans Teens”[8]. Georgie is sixteen and began taking puberty blockers at ten years and nine months in transitioning to female. Georgie argues that “the courts follow medical advice in their decision making anyway, making the courts [sic] process unnecessary”[9].

That politicians are keen to involve themselves in childhood gender dysphoria is confirmed by six US states and one in Canada which have declared it illegal to practise “conversion” or “reparative” therapy on minors. These confusing terms mean the only therapy that can be extended to minors with gender dysphoria is one that “affirms” their condition, and does not seek to “convert” or “repair” them back to their natal state. In 2017, bills to ban “conversion” therapy on minors have been filed in fourteen more US state legislatures.[10]

In Australia, the new Victorian Health Complaints Act has the potential for similar results. The Victorian Health Minister, Jill Hennessy, declared that the Act will “provide the means to deal with those who profit from the abhorrent practice of ‘gay conversion’ therapy … which inflicts significant emotional trauma and damages the mental health of young members of our community”[11]. She explained: “Any attempts to make people feel uncomfortable with their own sexuality is [sic] completely unacceptable.”[12] Though the minister specified “gay people” and did not define age, the Act could apply to any therapist not affirming a child’s gender considerations.

Overview of the cases reveals profound change in a short time, from dispassionate conviction for a protective role (supported by a submission from the Human Rights Commission), to passionate pleading in re Lucas[13] for laws to abolish the role of the court. Also, medical interventions have been performed at ages progressively younger than advised by international opinion. Blockers have been introduced at ten, not twelve; cross-sex hormones earlier than sixteen; irreversible surgery before eighteen.

Summaries also reveal a change in medical tone from traditional caution to a certitude that is rarely seen in other circumstances. Few doctors prophesy as fulsomely for the outcome of other problems as they do for the medicalisation of gender dysphoria. Rarely is such zeal indirectly proportional to evidence. Few doctors remain optimistic that chemical castration and surgical alteration of the genitals will ameliorate mental disturbance, though such therapies do exist in the distant history of psychiatry.

Along the way, the Family Court of Australia appears to have tired. Published judgments shrink from an average of twenty-eight pages in the first six cases from 2004, to seven and a half pages in recent cases (including three cases involving bilateral mastectomies). Does this reflect the influence of a small group of protagonists who argue that the court’s almost exclusive reliance on its testimonies renders the court an unnecessary intrusion into its business?[14]

Looking more closely at some cases

In re Alex (2004), the Family Court considered whether authority to consent for hormonal treatment should be given to guardians of a thirteen-year-old natal female identifying as a male. The case was complicated by Alex’s Gillick incompetence, depression, “perceptual disturbances” in which Alex “could hear his own voice or the voice of his father”, and sense that, as Alex said, “somebody can read my mind and the thoughts in my mind”.[15] The court was persuaded it was in Alex’s best interests to start medicines that would suppress menstruation and to continue with “irreversible” hormonal treatment at age sixteen.

The judge wondered if gender dysphoria was a disorder or merely a point in a rainbow of normality, acknowledging that some might find it “offensive” to have their condition categorised as “disease or malfunction”. He concluded, however, that the “current state of knowledge would not … enable a finding that the treatment would clearly be for ‘malfunction’ or ‘disease’” and thus “therapeutic” in the considerations of re Marion. Nevertheless, authority was given and, whether normal or not, Alex progressed from blockers to cross-sex hormones to bilateral mastectomy.

Re Brodie (2008) concerned a thirteen-year-old natal girl adamant she was a boy. Brodie existed in such a “tremendous state of turmoil and anger” at “betrayal” by an abandoning father that she was so difficult to handle her mother “was nearly ready to ask the State to take responsibility”. Arguing that puberty blockers would reduce the “hostility and anxiety”, therapists assured the court their effects were “completely reversible”, and their denial “would … endanger [Brodie’s] life”. The judge congratulated Brodie for being fortunate in having therapists who “continue to keep up with research” and who approached the matter with “sensitivity and reflection”[16].

In re Bernadette (2010), regarding a seventeen-year-old natal male identifying as female, the “Dutch protocol” appeared in Australian courts.[17] Philosophically, it was based on the ideology that sexual identity is determined by the mind and not the matter of “genitalia or other aspects of … physical appearance or presentation”. Practically, it formalised therapy into the stages described above.

Three other features stand out in re Bernadette. First, the judge was unable to be convinced that transsexualism was a “normally occurring factor of human development” which could be safely left to parental consent and, therefore, it was “in the best interests of every child” for the court to retain the authorising power. Second, for the first and last time in Family Court deliberations, concerns of “potential damage to the brain” by puberty blockers were raised.

In response, the judge declared he was “satisfied” the effect of Stage 1 therapy was reversible, despite the “British view … that brain development continues throughout adolescence” and blockage may incur “potential damage”. The judge concluded that “this aspect” is dealt with by the Dutch professors who “comment on the need for a study on the brains of adolescent transsexuals to endeavour to detect functional effect and difficulties”. He said “this potential aspect of the matter” would not cause him to deny treatment. Thus the judge appeared satisfied there would be no brain damage in the present on the basis of research to be pursued in the future.

Third, the judge declared, “so far as stage 2 is concerned, I am satisfied that it would be possible to reverse that treatment”. It appears attention was not drawn to research already reporting effects of cross-sex hormones on brains, as discussed below.[18]

Re Jamie (2011) was a saga that continued into the Full Court in 2012, 2013 and 2015. It concerned a natal twin boy of ten years identifying as a girl. In 2011, Jamie was declared Gillick competent to consent to puberty blockers despite the fact it was “difficult to ensure” he understood “the full and extensive ramifications of such decisions, especially in the long term”, and that the blocker would be administered at an age less than researched and, therefore recommended, in Holland.[19] Declaring blockers “safe and entirely reversible”, the court decided there was no need for its protective role, and their administration could be left to therapists.

The court decided, however, that the “nature … of Stage 2” was such that authorisation would still be needed for parental consent to the child’s treatment, unless the child demonstrated “Gillick competence”, in which case the court could authorise the child to consent. If not, the court would decide what was in the “child’s best interests”. Thus, the role of the court was to establish Gillick competence. If that was established, the court would have no further role.

In 2015, the court heard that, after almost four years of blockers, Jamie was approaching fifteen with the appearance of a “pre-pubescent girl … [who] does not resemble her female peers, particularly in terms of development of breasts”. Deducing psychological stress, the court pronounced Gillick competence, authorising oestrogens.

There was a major turn in the reasoning of the court in Jamie’s saga. The need to protect the “best interests” of the child was subsumed to the concept that it could consent to irreversible, possibly grave, intervention as long as it could convince the court it knew what it was doing. The court was now dependent on therapists. Without their opinions, how could it evaluate competence?

It is ironic that Jamie’s parents appealed to the Full Court with the argument that gender dysphoria was, in fact, a mental disorder which warranted psychiatric medication for “a malfunction or disease”. This argument contradicted the popular claim that transgender orientation was merely a point in rainbow normality.

In 2013, in re Sam and Terry, Sam was a natal boy identifying as a girl, and Terry, a girl identifying as a boy. Both were Gillick incompetent. Sam suffered severe mental co-morbidities of anxiety, depression, eating disorder and social phobia and was, essentially, housebound. Terry suffered from Asperger’s syndrome. Approval was sought and received by parents for administration of Stage 2 therapy.

The court reaffirmed its need to be the “decision maker” in the best interests of the child, revisiting reasons from re Jane[20], including the need to protect from removal of a “girl’s clitoris for religious or quasi-cultural reasons or the sterilisation of a perfectly healthy girl for misguided, albeit sincere, reasons”. A psychiatrist opined that gender dysphoria “does not require psychiatric treatment. The treatment it requires is gender transition which is a medical and surgical process.” The irony seems unappreciated that such treatment for a rainbow culture could lead to both clitorectomy and sterilisation[21].

Disagreeing with the psychiatrist by declaring gender dysphoria was, indeed, within the ambit of a “psychiatric disorder”, the judge seemed unaware of the status being conferred upon gender dysphoria: the only psychiatric illness still treated by surgery on the genitals.

By 2015, attitude had swung towards the concept of transgender being normal, though no particular reason emerges from cases in 2014. “Pleasingly”, the judge declared in re Cameron[22], gender dysphoria is “not now generally considered a mental illness”. And, though the natal girl “did not have full understanding”, the court “wishes him well, acknowledging the maturity and courage he has shown”, while authorising cross-sex hormones.

By 2016, certitude in testimonies before the court had become almost evangelical. In re Celeste[23], new life was prophesied for a natal male transitioning to female: cross-sex hormones “would maintain … self esteem, retain her congruence of self as a young woman and facilitate her normative psychological, social and sexual development”. These prophecies were, however, difficult to reconcile with other testimony that at four years of age the child had been diagnosed with Asperger’s syndrome, attention deficit/hyperactivity disorder and language disorder, whose ongoing effects had reduced his capacity to attend and concentrate at school. In summary, it was admitted that “she” does not “understand everything that is said to her”.

In re Gabrielle,[24] which involved another natal male identifying as female, the court found that oestrogens were necessary for the child to “continue living happily” and their denial “would result in a loss of recognition and validity of her sense of self … depression and anxiety [will] increase … and [she] will be at greater risk of self harm and death from suicide”. Paradoxically, it was also asserted that if Gabrielle ever wanted to revert to being a male after all that positive experience as a female, “she has the thoughtfulness and creativity to be able to manage … de-transition comfortably”. In fifty-one years of medicine, I have never heard medical “happiness” prophesied.

The certitude of 2016 was extended to three bilateral mastectomies. International guidelines for irreversible surgery were interpreted as merely advice, and minimised with the argument that it would be limited to the breasts and not involve the reproductive organs (as described in my previous Quadrant article, “The Fashion in Child Surgical Abuse”, December 2016).[25]

Questioned about possible after-effects of the operation, one teenager replied that “he” would just have to “stay on the couch and watch Netflix for some weeks” and might have to “miss the formal”. Was this nonchalance, or incomprehension of life-long implications?[26]

Another seeking mastectomy was declared to be “not very knowledgeable about … side effects and complications of the surgery” but this “did not strike me [the doctor] as being out of keeping with his stage of development”. On advice, the judge declared Lincoln[27] competent to consent but, equivocating, he added, “if I am wrong … I accept the submission of all parties … that the proposed treatment is in the best interests of Lincoln”. One way or another, Lincoln was going to lose her breasts. She had been on blockers for almost two years and cross-sex hormones for six months, but this was not considered to have affected the structure of her brain and, thus, cognition.

In re Lincoln, the judge set the stage for future loss of breasts and even genitalia by declaring he could not understand how a child could consent for Stage 2 therapy and not Stage 3 because both involved irreversible effects. Because of doubt as to whether Lincoln was Gillick competent, the judge also set the precedent for others to make decisions on behalf of the breasts of minors.

Deliberation over the fate of Lincoln[28] has probably set yet another precedent. One therapist argued that the age of administration of sex hormones should be lowered from sixteen to soon after the start of puberty (which normally occurs around nine in girls and ten in boys). He declared: “lagging behind their peers in pubertal development” creates its own “psychological stress”. Therefore, Stage 2 should be started at a lower age if the “diagnosis is clear cut”. The therapist did admit but did not specify a cognitive effect of blockers.

Facilitating entry to Stage 2, in re Darryl[29], the court rejected the assertion by an expert witness that the natal female who was prone to depression and self-harming did not have “the competency to consent to irreversible treatment”. Uniquely, that witness had continued, “given the grave consequences, I am not persuaded that most minors would be in the position to fully understand the implications of irreversible hormone treatment over the entire lifespan”.

The judge disagreed, declaring “there can be no doubt” about Darryl’s competence. In any case, the judge concluded he did “not accept that the words ‘understand fully’ require a child to have achieved the maximum understanding which later years may give them when their brain and personality are fully developed”. The judge appeared convinced that full development would not bring recognition of a grave mistake in disturbed adolescence.

The 2016 cases ended with a call in re Lucas[30] for abolition of the role of the court in gender dysphoria. Regarding a seventeen-year-old natal girl seeking authority for testosterone, the judge declared an “urgent need for statutory intervention … to undo the consequences of re Jamie”. Rejecting the declaration of the Australian Human Rights Commission in Jamie, the judge pleaded for the abolition of the need for the court to authorise Stage 2 therapy, implying the child should be left in the hands of therapists. Confirming his view that biology should be moulded to the mind, he asked, “What other section of our youth is required to endure such an ordeal to attain the corporeal manifestation of their [sic] identity?”

The cerebral effects of blockers and cross-sex hormones

It was first thought that the action of GnRH was specific to the pituitary gland but, as early as 1981, a role in other parts of the brain was being revealed[31]. By 1987, it was established that many of the nerve cells that produced that hormone were connected to other neurons in widespread parts of the brain, such as the limbic system, which is fundamental to executive, behavioural and emotional control[32]. These findings were confirmed[33] [34] [35], showing receptors for GnRH were expressed in numerous areas in the brain not involved with reproduction. They raised questions of what might result if the actions were blocked[36], especially in puberty, the “critical window for neuronal development and programming”[37].

By 2004, it was known that surgical castration of male animals can lead to “profound loss of synaptic density in the hippocampus and changes in learning and memory”[38] [39] due to absence of testosterone. Synapses are the junctions between cells through which information is shared by tiny electrical impulses or chemical transmitters. Their reduction implies reduced or altered activity of that region of the brain. GnRH blockers are a means of chemical as opposed to surgical castration, therefore, the effect of reduction of testosterone by blocking the pituitary needed to be elucidated.

By 2007, as animal and behavioural studies suggested blockers “may have significant effects on memory” their effects were examined in humans. Interference in memory and executive function[40], and abnormal cerebral function was found in women receiving blockers for gynaecological reasons.[41]

In 2008, review of the effect of testosterone deprivation due to blockers in men receiving them for prostate cancer raised the “strong argument” that blockers, alone, caused “subtle but significant cognitive declines”.[42] Other studies confirmed “higher rates … of cognitive impairment” compared to controls[43], but were denied by some.[44] Laboratory studies were needed.

In 2009, scientists in universities in Glasgow and Oslo had begun collaborative research on the effect of blockers on the behaviour and brains of sheep. These foundational studies revealed that exposure of the pre-pubertal lamb to blockers led to an observable increase in the size of the amygdala[45], that the activities of a large number of genes in the amygdala and hippocampus were altered by the blockers[46] [47] and, not surprisingly, that some aspects of brain function were disturbed [48][49]. Female sheep had less emotional control and were more anxious. Males were more prone to “risk taking” and alterations in emotional reactivity. Males suffered reduction in spatial memory that persisted after treatment.[50]

These results suggest that blockers may alter the shape of the brain and the capacity of cells to communicate with each other at a molecular level[51] [52]. This could be due to a direct effect of the loss of GnRH or, alternatively, a reduction in GnRH-dependent production of local neurosteroids involved in the formation of synaptic connections when the brain is developing.[53] [54]

Contrary to the laboratory studies, a recent study by the Dutch group[55] on its own human patients asserted that no difference could be found in executive function between mid-teens on blockers and controls. Little reassurance can be gained from this conclusion, however, because close reading of the results reveals that males on blockers transgendering to females did have “significantly lower accuracy scores than the control groups”. However, the authors declared that “it is possible that this is just a chance finding due to the small size of the subgroup (of eight adolescents)”. Alternatively, it could have confirmed what had been revealed in sheep; but, indeed, the numbers were small.

Other psychological studies have suggested positive outcome in humans on hormonal therapy but all are weakened by small numbers and their reliance on observations by involved therapists.[56] Reviews stress lack of evidence[57]. It should be emphasised that, unlike older men with cancer whose brains are deteriorating with age, children are being given blockers at a time of great brain development. Moreover, compared to the men whose treatment lasted only months, many children receive blockers for years.

Cross-sex hormones

Courts have repeated the testimony of experts that the effects of cross-sex hormones are “partially reversible”. However, in none of the summaries does it appear that attention has been directed to the possibility of structural change on the brain, despite occasional warnings about mood swings, depression and anger.

Animal studies mentioned above on the effects of androgen deprivation should have raised concerns about similar effects of puberty blockers on the brains of natal boys. The added effect of oestrogen should have been considered because by 2006 it was described in medical literature.

Three studies have compared the effects of cross-sex hormones on the brain before and after treatment. One, in which oestrogen and an added anti-testosterone drug were given to transgendering males, found a reduction in brain “ten times the average annual decrease in healthy adults” after only four months. After a similar time, the brain volume increased in females receiving testosterone.

Other studies[58] confirm that shrinkage of male brains on oestrogen is associated with reduction in the size of grey matter after only six months. Increased size of grey matter in females on testosterone is associated with altered microstructure of neurons[59].

Oestrogen may reduce grey matter in males by inducing apoptosis, or death of neuronal and supporting cells. Testosterone may increase the size of female grey matter by an anabolic effect on molecular components of cells. As brains are chromosomally programmed before birth to respond to specific stimulation of appropriate sex hormones in puberty, there should be no surprise at disruption when the hormone they were expecting has been substituted by one they were not.

As with blockers, the above studies were conducted on adult brains exposed to cross-sex hormones for only several months. What can be expected from exposure in childhood that continues for decades? No one knows. A 2016 review concludes that “long term clinical studies are yet to be published … risks may become more apparent as the duration of hormone exposure increases”[60].

Conclusion

Blockers and cross-sex hormones cause structural alterations in the brain. No one knows the long-term effects. Their use in treating childhood gender dysphoria is utterly experimental. There is no reliable evidence of long-term benefit to recipient children. Most will grow out of gender dysphoria by puberty. So why medicalise the confusion?

Children and parents caught up in the transgender phenomenon deserve our compassion. The children are in great danger of psychological imprinting by a Gnostic ideology whose enlightened leadership declares mind is truly over matter: feelings trump chromosomes, and gender is fluid. The danger increases exponentially when children enter the pathway of medical experimentation. Who can protect them from this current fad, fuelled by the media and instructed by websites?

Lamentably, Australian courts seem to be tiring of the protective role declared necessary in Marion’s case. At least one judge is calling for the abolition of the role for the courts in gender dysphoria and would leave treatment entirely in the hands of therapists.

There are, however, at least two problems in such unauthorised therapy. The first is that of human nature, to which Marion’s case alludes. The medical profession is not alone in having sincere but misguided practitioners and the consequences of mistakes regarding childhood gender dysphoria are, indeed, irreversible and grave. Family courts have praised therapists for their knowledge but while those experts have been propounding the cerebral safety of hormonal treatment, international research has been proving otherwise.

The second problem is the new Victorian Health Complaints Act, which has the potential to restrict all therapists to affirmation of gender dysphoria.

Affirming therapists may face their own dangers. Patients may emerge with altered brains, asking why no one warned them about such things. The High Court in Rogers v Whittaker[61] declared that “a medical practitioner has a duty to warn a patient of a material risk inherent in the procedure”. In that case, an ophthalmologist did not think to warn a patient of the one-in-14,000 risk to the good eye when operating on the bad. Regarding the brain and hormonal treatment for gender dysphoria, reports of damage are established, and ignorance can be no defence.

Dr John Whitehall is Professor of Paediatrics at Western Sydney University. A footnoted version of this article appears at Quadrant Online.



[1] De Vries A, Cohen-Kettenis. J Homosexuality. Clinical management of Gender dysphoria in Children and Adolesecents: the Dutch Approach. 2012. 59 (3):301-316.

[2] World Professional Association for Transgender Health. Standards of Care. 2011 Accessed Feb 27, 2017,

[3] Information is available on 39 families. In 22 there are single parents, 3 are in foster care, and 14 in apparently double parented families.

[4] Gillick vs West Norfolk and Wisbech Area Health Authority. (Gillick’s case) (1985)UKHL. 1986)AC 112.

[5] Re Marion, at 237-238.

[6] Re Marion at 237-238.

[7] Re Jane (1988). 94 FLR 1.

[8] https://www.transcendsupport.com.au

[9] Triple J Hack. Sarah McVeigh. Georgie Stone wins GLBTI person of the year: Globe Awards.October 23.2016

[10] https://en.wikipedia.org/wiki/List_of_U.S._jurisdictions_banning_conversion_therapy_for_minors

[11] Hennessy J. Health Complaints Bill 2016. Victoria Legislative Assembly. February 10, 2016. Second Reading. Hansard p98.

[12] Hennessj J, as reported in Zero tolerance: Andrews to crack down on gay “conversion” therapy. The Age. Jan 24, 2016

[13] Re Lucas (2016). FamCA.

[14] Telfer M, Tollit M, Feldman D. Transformation of health-care and legal systems for the transgender population: the need for change in Australia. JPCH.2015;51:1051-1053.

[15] Re Alex 68.

[16] Re Brodie. FamCA 776, (2007) and FamCA 334, 2008.

[17] Re Bernadette. 2010 FamCA 94.

[18] Hulshoff Pol, H. E., Cohen-Kettenis, P. T.,Van Haren, N. E., et al. Changing your sex

changes your brain: Influences of testosterone and estrogen on adult human brain structure. European Journal of Endocrinology,. (2006).: 155,:S107–S111.

[19] Re Jamie (2011). Fam CA 248.

[20] Re Jane (1989). FLC 92-007 (at 77, 256).

[21] Whitehall J. The fashion in child surgical abuse. Quadrant. December 2016.

[22] Re Cameron. (2015). FamCA 1113.

[23] Re Celeste. (2016) FamCA 503.

[24] Re Gabrielle (2016). Fam CA 470

[25] Whitehall J. The fashion in child surgical abuse. Quadrant. December 2016.

[26] Re Quinn. (2016) FamCA.

[27] Re Lincoln (2016) FamCA 1071.

[28] Re Lincoln 2016) FamCA 267.

[29] Re Darryl (2016) FamCA 720

[30] Re Lucas (2016). FamCA.

[31] Eiden, L,. Brownstein M. Extrahypothalamic distributions and functions of hypothalamic peptide hormones. Fed. Proc. 1981 40: 2553-2559. Eskay

[32] Silverman A, Jhamandis J, Renauld L. Localisation of luteinising hormone releasing hormone (LNRH) neurons that project to the median eminence. J Neurosci 1987;72:312-2319

[33] Wilson A, Salamat M, Haasl R et al. Human neurons express type 1 GnRh receptor and respond to GnRH by increasing luteinizing hormone expression. J Endocrinol. 2006;191:651-663.

[34] Skinner D, Albertson A, Navratil A et al. Effects of gonado-trophin releasing hormone outside the hypothalamic-pituitary-reproductive axis. J Neuroendocrinol. 2009;21:282-292.

[35] Skinner D, Albertson A, Navratil A et al. Effects of GnRH outside the Hypothalamic-Pituitary-Reproductive Axis. J Neuroendocrinology. 2009:282-292.

[36] Carel J, Eugster E, Rogol A et al. Consensus statement on the use of GnRH analogs in children. Pediatrics 2009. 123. E752-762.

[37] Berenbaum S, Beltz A. Sexual differentiation of human behaviour:effects of prenatal and pubertal organisational hormones. Front. Neuroendocrinol 2011.32:183-200

[38] Leranth C, Prange-Kiel J, Frick K et al. Low CA1 spine synapse density is further reduced by castration in male non-human primates. Cerebral cortex. 2004;14:503-510.

[39]Bussiere J, Beer T, Neiss M et al , Androgen deprivation impairs memory in older men. Behavioral Neuroscience, Vol 119(6), Dec 2005, 1429-1437.

[40] Grigorova M, Sherwin B, Tulandi T.Effects of treatment with leuprolide acetate depot on working memory and executive functions in young premenopausal women. Psychneuroendocrinology. 2006:31:935-947.

[41] Craig MC et al. Gonadotropin hormone releasing hormone agonists alter prefrontal function during verbal encoding in young women. Psychoneuroendocrinology. 2007;8-10:116-117

[42] Nelson C, Lee J, Gamboa M et al Cognitive effects of hormone therapy in men with prostate cancer: a review.Cancer. 2008 Sep 1;113(5):1097-106.

[43] Jim H et al. Cognitive Impairment in Men Treated with Luteinizing Hormone-Releasing Hormone Agonists for Prostate Cancer: A Controlled Comparison. Support Care Cancer, 2010.18(1):21-7.

 

[44] Salminen E, Portin R, Korpela J, Backman H Androgen deprivation and cognition in prostate cancer.Br J Cancer. 2003;89(6):971-6

[45] Nuruddin S, Bruchhage M, Ropstad E et al. Effects of peri-pubertal gonado-tropin releasing hormone agonist on brain development in sheep…a magnetic resonance imaging study. Psychoneuroendocrinology. 2013;38;3115-3127.

[46] Nuruddin S, Wojniusz S, Ropstad E et al. peri-pubertal gonado-tropin releasing hormone agonist treatment affects hippocampus gene expression without changing spatial orientation in young sheep. Behav. Brain Res. 2013.;242:9-16.

[47] Nuruddin S, Krogenaes A, Brynildsrud ) et al. Peri-pubertal gonadotropin-releasing hormone agonist treatment affects hippocampus gene expression without changing spatial orientation in young sheep. Behav Brain Res. 2013;242:9-16.

[48] Wojniusz S, Vogele C, Ropstad E et al. Prepubertal gonado-tropin-releasing hormone analog leads to exaggerated behavioural and emotional sex differences in sheep. Hormones and Behaviour. 2011;59:22-27.

[49] Evans N, Robinson J, Erhard H et al. Development of psycophysiological motoric reactivity is influenced by peripubertal pharmacological inhibition of GnRH action-results of an ovine model. Psychoneuroendocrinology. 2012; 37:1876-1884.

[50] Hough D, Bellingham M, Haraldsen I et al., 2017 Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology. 2017; 75:173-182.

 

[51] Hough D, Bellingham M, Haraldsen I et al., 2017 Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology. 2017; 75:173-182.

[52] Hough D, Bellingham M, Haraldsen I et al., A reduction in long-term spatial memory persists after discontinuation of peripubertal GnRH agonist treatment in sheep. Psychoneuroendocrinology. 2017; 77:1–8.

[53] Naftolin F, Ryan K, Petro Z. Aromatization of androstenedione by the diencephalon. J Clin Endocrinol Metab. 1971;33;368-370.

[54] Prange-Kiel J, Jarry H, Schoen M et al. Gonadotrophin releasing hormone regulates spine density via its regulatory role in hippocampal oestrogen synthesis. J Cell Biol. 2008;180:417-426.

[55] Staphorsius A, , Kreukels B, Cohen-Kettenis P et al. Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dsyphoria. Psychoneuroendocrinology. 2015;56:190-199.

[56] De Vries A, McGuire J, Steensma T et al. Young adult psychological outcome after puberty suppression and gender reassignmnent. Pediatrics. 2014;134(4):

[57] Fuss J, Auer M, Briken P. Gender dysphoria in children and adolescents: a review of current research. Current opinion in psychiatry. 2015.

[58] Zubiaurre-Elorza, L., Junque, C., Gomez-Gil, E., & Guillamon, A. (2014).

Effects of cross-sex hormone treatment on cortical thickness in

transsexual individuals. Journal of Sexual Medicine, 11, 1248–1261.

[59] Rametti, G., Carrillo, B., Gomez-Gil, E., Junque, C., Zubiaurre-Elorza, L.,

Segovia,S.,…Guillamon,A. (2012).Effects of androgenisation on the

White matter microstructure of female-to-male trans-sexuals. Adiffusion

tensor imaging study. Psychoneuroendocrinology, 37, 1261–1269.

[60] Guillamon A, Junque C, Gomez-Gil E. A Review of the Status of Brain Structure Research n

Transsexualism. Arch Sex Behav (2016) 45:1615–1648

[61] Rogers vs Whittaker (1992) 175 CLR 479.