On May 24, the ABC’s Australian Story told of children rescued from disaster by Dr Michelle Telfer, attractive, dedicated, youthful paediatrician, mother, former gymnast, and head of the gender dysphoria clinic in Royal Children’s Hospital, Melbourne. Having been born into the wrong body, but now given ones by Dr Telfer that would match their minds, the children appeared set to live “happily ever after” (and I hope they do), as blessed by the husband and wife pastors of “progressive” Christianity (though resplendent in the black regalia and white dog collars of yore) whose own child is amongst the transformed.
Gratitude for salvation was as exuberant as condemnation of evil. How dare some describe the salvific process as “experimental”? How dare the Australian newspaper seek evidence for hormonal resurrection? How dare an old, white male paediatrician raise the spectre of “castration” when reproduction may surely be achieved by taking biopsies of ovaries and testicles before their damage by chemicals, or their removal in surgery, in frozen expectation of the later miracle of in vitro fertilisation? Or by the emergence of a baby from a uterus hidden in a masculinised corpus to suckle amongst the foliage of a hirsute chest?
This essay appears in the latest Quadrant.
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In such stories, as of old, the listener might expect the emergence of some clear principles of life, some signposts to truth. Better still, the fairy grandmother might share the truth, the whole truth and nothing but the truth: certainties upon which you could stand secure. Sadly, “A Balancing Act: Michelle Telfer” is poorly named.
The first imbalance: the effects of blockers are reversible
To the upturned face of a trusting eleven-year-old natal boy who had become “sick of living in her body”, and who just happened to ask “How do puberty blockers work?”, Dr Telfer explained that the drug “gives you time to think about what you want to do in the long term without you having to worry about your voice dropping or going hairy or any of those things”.
She reassured the child, “puberty blockers are reversible. The only risk is that [they] can affect your bone density and, if you decide in a couple of years … [you] don’t want to be a female … we can stop this drug and your body goes back to how it would have been”. To a wider audience, she declared blockers provide “time to … mature cognitively and emotionally” so that “when the time comes she would be competent to make that decision on her own”.
Blockers suppress the vertical cascade of hormones, from hypothalamus to pituitary to gonads and then to body, that bring about the changes of puberty. If stopped, the process may resume, giving partial justification for the word reversible. Problems, however, lie in the associated blocking of the broader, say horizontal, functions of Gonadotropin Releasing Hormone (GnRH), as it is named, whose receptors are found throughout the brain, in regions involving cognition, emotion, memory, reward and sexuality. Extensions of the nerve cells producing GnRH in the hypothalamus actually extend horizontally into the limbic system, while distribution of their product to other regions may occur through cerebro-spinal fluid.
International research refutes the claim of “reversibility”. For example, researchers in Glasgow and Oslo universities have long demonstrated sustained, deleterious effects of blockers on peri-pubertal sheep (whose lengthy period of puberty is relevant for human comparison). Blockers invoke pathological enlargement of components of the limbic system, associated with interruption of the function of many genes in the amygdala and hippocampus whose role should be the preservation of the integrity of neuronal cells. In consequence, there is lasting reduction in spatial memory and increased emotional lability, reducing performance in mazes. Male sheep become more gung-ho, females more fearful in their confusion.
Recently, from New York, researchers report “behavioral and neurological” effects of blockers on mice. The sexual behaviour of rodents might seem esoteric, but the authors explain that the model “has the potential to isolate the biological effects of GnRH … on brain function and behavior from the dysphoria and psychological distress associated with incongruence between gender identity and natal sex”.
In females, blockers resulted in “profound effects” on behaviour, interpreted as depression (despair-like behaviour), and on the neural activity in the hippocampus, “a brain region crucially involved in stress processing, depression and cognition”. Blocked males exhibited “pronounced differences in locomotion [they were hyperactive] and social preference [they preferred the company of males, and showed none of the usual interest in the opposite sex], and increases in neuroendocrine responses to stress”.
In humans given blockers to reduce the provocative effect of sex hormones in such diseases as endometriosis and prostate cancer, research has long reported unwanted effects on cognition, emotions and executive function, though conclusions are rendered difficult by the confounding effects of age, disease and other treatment.
Studies on the developing brain of adolescents are very limited but should temper claims of reversibility. In one transgendering adolescent, two years of blockers prevented expected brain development, and were associated with some reduction in operational memory. The authors speculated on disruption of the synchronic development of the brain.
Outside the brain, biopsies, investigating the increased incidence of intestinal symptoms in women receiving blockers for endometriosis, have revealed marked a reduction in the nerve cells directing peristalsis, adding clinical weight to laboratory contention that GnRH has a widespread role in maintaining neuronal integrity.
Thus, there is no evidential support for the fulsome assurance of “reversibility”. To the contrary, there is evidence and strong suggestion of damage.
The second imbalance: they provide time for wisdom
The claim that blockers provide time for the gaining of wisdom regarding sexuality and the capacity for informed consent to massive intervention is biologically implausible.
Sexuality. Sex-specific organisation of the brain occurs within weeks of conception, to await further organisation and activation of specific centres during puberty. Blockers neuter the latter process.
Decades ago, a “primary” mid-brain centre was identified which, when activated by GnRH in immature animals, resulted in sexualised behaviour. Denied that activation, sexualisation did not occur.
As well, researchers have long known that “socio-societal effects” can stimulate sexualisation in animals. It is known as the “ram effect”, in which a range of olfactory, auditory, visual, tactile and social stimuli was found capable of inducing ovulation in females. Still not well understood, this sexualisation is dependent on GnRH.
In humans, the secondary effects of the GnRH-dependent gonadal sex hormones, testosterone and oestrogen, range from behaviour, to cognition and emotions, to physical manifestations and, of course, sexualisation and libido.
The question is, how can a child establish sexual identity when denied the creative effects of primary and secondary centres upon which it depends, and when neurons are interrupted in the brain centres that integrate sex with cognition, emotion and experience?
The brain. Enormous developments begin with puberty and continue into early adulthood, with GnRH and the sex hormones being members of a chorus of stimulants. Maturation of various regions, however, is not synchronous. For example, the forebrain usually lags behind the limbic system, resulting in the risk-taking of adolescent males and the reticence of females. Wisdom, however, depends on a balance of cognitive, emotional and experiential factors.
Society recognises the imbalance of adolescence and denies adolescents access to alcohol, tattoos, driving cars and joining the army. To the contrary, the Royal Children’s Hospital in Melbourne insists on a special exemption for gender-confused children: they should be granted special “agency” for massive intervention of lifelong importance, despite lack of supporting evidence and the growing ranks of “desisters” who regret they were not protected from their immaturity.
Two other biological factors are relevant to consideration of the capacity for informed consent in children on hormonal intervention. First, the observation that almost all children who start on blockers proceed to cross-sex hormones is argued to be confirmation of maturity of decision. But, studies on blocked sheep and rodents suggest an alternative, iatrogenic explanation: blockers interfere with the limbic system, reducing exploration and increasing fearfulness. The animals prefer the familiar to the novel: they avoid change. Thus, the decision to progress to cross-sex hormones may not represent wisdom, merely the role of chemical tram-tracks.
An associated psychological pressure to proceed to cross-sex hormones is that of the difficulty of rejection of the adopted persona in the face of all those authority figures in the family, the school, the web and the hospital.
Second is the effect of cross-sex hormones on the brain. Researchers have found the adult male brain shrinks at a rate ten times faster than ageing after only several months of exposure. The female brain hypertrophies. The effect on the growing brain of adolescents can only be imagined: there are no studies. And the adolescents are likely to be on them for life. Can straight thinking be presumed in an altered brain?
The question is, how can society permit agency for such massive interventions when the vagaries of cerebral development are already known, and there is established proof of interruption to function and structure by the very chemicals about to be administered?
Some external balance
Lately, some major authorities have concluded, contrary to the Melbourne hospital, that children do not possess the capacity for informed consent for hormonal and surgical transgendering. Sadly, the ABC is not the place to obtain a balanced view of these things.
In June 2020, the Council for Choices in Health Care in Finland, having declared that “gender re-assignment of minors is an experimental practice”, insisted that
first-line intervention … is psycho-social support … [which] should be provided in school and student healthcare and in primary healthcare for the treatment of gender dysphoria due to variations in gender identity in minors.
Gender identity assessment may be considered only after “other psychiatric symptoms have ceased and adolescent development is progressing normally”. Rigorous research should “collect extensive information on the diagnostic process and the effects of different treatment methods” and no “irreversible treatment” should be initiated.
On December 2020, the UK High Court concluded, on the basis of “limited evidence … of efficacy or purpose” for hormonal “affirmation”, that:
There will be enormous difficulties in a child under 16 understanding and weighing up this information and deciding whether to consent to the use of puberty blocking medication. It is highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences of the administration of puberty blockers. For ages between 16 and 18, the court considers it advisable to request a court approval before starting hormonal treatment, since the treatment should be regarded as experimental.
In consequence, the NHS discontinued initiating hormonal treatments in children under sixteen.
In April 2021, the government of Arkansas banned hormonal “affirmation” and surgery for children under eighteen, and other US states may follow. In May 2021, Sweden’s Astrid Lindgren Children’s Hospital stopped prescribing blockers and cross-sex hormones to children under eighteen.
Meanwhile, in February 2021, the Victorian parliament approved legislature to incarcerate for up to ten years and inflict crippling fines on anyone seeking to “change or suppress” another’s sexual orientation or gender identity, thus mandating referral of a dysphoric child to Dr Telfer’s clinic.
The third imbalance: hormonal “affirmation” is not the only treatment
The ABC’s Australian Story promotes the idea that “affirmation” is the only therapy available and that “doing nothing” increases the suffering of the child, leading to self-harm and even suicide. This promotion is false on two accounts: no one advocates doing nothing, and individual and family psychotherapy with attention to social and co-morbid mental disorder does not equate with “nothing”.
To the contrary, such therapy is associated with the statistical reality that the large majority of dysphoric children re-orient to congruity with chromosomes as they progress through puberty. Such psychotherapy has long been practised in Australia. For example, in Western Australia, child psychiatrist Robert Kosky admitted to hospital the eight children referred to the gender service between 1975 and 1980, reporting a “generally good outcome” and warning that the disrupted “familial and social context … should counteract undue emphasis on the aberrant behaviours themselves”. International literature confirms such therapeutic intervention and must underpin the recent decisions by Finland, Sweden and elsewhere to consider it “first line”. Perhaps the best-known program of psychotherapeutic intervention is that of the Canadian psychologist Kenneth Zucker, who was amongst the first to report that most dysphoric children will orientate to congruence with chromosomes.
It is worthwhile comparing Zucker’s program with that of Melbourne, as described by Dr Telfer in Australian Story. In his review of the Biopsychosocial Model of Care that had been offered to the 590 children referred to his unit in its thirty-five years of existence, Zucker details an exhaustive approach of telephone discussion, at least six child/parent interviews, and evaluations of some twenty checklists, questionnaires and school reports. Subsequent therapy involved scores (sometimes hundreds) of counselling sessions, over many years, whose aim was to help the child become “comfortable in the skin” in which it was born.
Dr Telfer reported that 473 children had been referred to her Melbourne clinic in 2020 alone, though, perhaps defensively, she assured us that “more than 20 per cent never go beyond the first assessment”. Of those “who do feel that medical affirmation is necessary for them, they will see either a psychologist or a psychiatrist at least three times before they see anyone like a paediatrician or an endocrinologist who might start to consider whether a medication is going to be something to help”.
In Melbourne, numbers have soared, assessment appears rudimentary, psychotherapy is absent, and the goal appears different: more about making the skin fit the brain. Dr Telfer’s enthusiasm is indicative: she recalls thinking, “I can help this [natal girl] child have a boy’s body … how many people can do that?”
Zucker’s intensive and prolonged program (and similar programs) became known, inaccurately, as “wait and see”. That misleading description appears to have facilitated the program’s derogation to “doing nothing”: except, of course, to warranting criminalisation in Victoria. What is the ideological compulsion behind that criminalisation?
The fourth imbalance: childhood gender dysphoria and suicide
There is no doubt: those evincing the distress of gender dysphoria are suffering, vulnerable children, usually emerging from broken homes and burdened with co-morbid mental disorders, including autism.
Authors from the Children’s Hospital at Westmead, Sydney, emphasise that their developmental pathways “are shaped, at least in part, by adverse childhood events (including maltreatment), loss of family stability and cohesion” as well as socio-economic factors. They note that “co-morbid psychiatric diagnoses” occurred in 87.7 per cent, and that histories “of self-harm, suicidal ideation, or symptoms of distress were also common”. Of relevance to the discussion above, the authors declare:
treatment interventions … require a comprehensive biopsychosocial assessment with the child and the family, followed by therapeutic interventions that address, insofar as possible, the breadth of factors that are interconnected with each particular child’s clinical presentation.
Would such interventions land the authors in jail in Victoria?
Although it is well known that children suffering social and mental burdens may harm themselves and, therefore, demand special attention, there is no evidence that gender dysphoria per se leads to suicide and therefore justifies the massive intervention of hormonal transformation. To the contrary, there is epidemiological evidence that transgendered adults suffer a rate of suicide some twenty times higher than the general population. Thus, one way for prevention of that tragedy might be helping the child to become more comfortable “in the skin in which it was born”.
Proponents for “affirmation” blame ostracism for the high rate of adult suicide, but of equal importance might be associated mental disorder, failure to find expected gold at the end of the rainbow (ask any of the growing crowd of desisters) or, dare it be said, the alteration of pathways vital to a sense of well-being by iatrogenic administration of chemicals.
The problem is evaluation of the contribution of associated fellowship in the process of “affirmation” in childhood. Rightly so, in the gender clinics, the suffering of the children is likely to be enwrapped in unprecedented encouragement, attention, compassion and care, indeed, in the love of many adults, not to mention psychological affirmation from friends, the web, acknowledgment at school and even promotion in the media. What childhood suffering would not be blessed by that warmth? The danger, according to statistics, lies in the cold, lonely years of transgendered adulthood. May the children in Australian Story never face such challenges.
The imbalanced ABC
Impartiality is claimed to be “one of the most fundamental elements of content making in the ABC”. Its stated goal is to ensure audiences will receive “fair and unbiased information which will help them to gain a reasonable understanding of an issue and to make up their own minds”.
This “fundamental element” is lacking in the ABC’s portrayal of gender dysphoria in children. Its repeated proclamation to the masses of a few simple, unquestioned, one-sided assertions better deserves the appellation, “propaganda”.
Suppression of alternative opinions characterises all revolutions. Will it be cancelled in such platforms as the Australian? Remember: powerful activists in Victoria have proclaimed the need to abolish “public broadcasts” that hinder the “affirmative” model of hormonal therapy for confused children.
How long will the tax-funded ABC remain a voice for cultural revolution?
Dr John Whitehall is a professor of paediatrics at a Sydney university. He has written extensively on this topic in Quadrant over recent years.
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