In August, the Family Court of Australia considered the provision of cross-sex hormones to a 16-year-old natal male seeking to transgender with the approval of the father but in opposition to the mother. An earlier Court had suggested the current court might raise the question of whether such hormonal therapy was ‘therapeutic’, but this did not eventuate. Instead, the Court declared in favour of their continued administration in disregard of side effects.
A complication unvisited by the Court was that female hormones had been administered for almost a year before the Court met to consider its approval. They had been prescribed by an endocrinologist until he stopped doing so in anticipation of the legal proceedings. In response, the father began to import the same brand of sex hormones and to administer them in the same dose. Monitoring blood tests of this illegal procedure were performed by unnamed medical practitioners.
The original prescriber defended their administration by arguing they were not given as Stage 2 therapy, the evocation of external characteristics of the opposite sex in the process of transgendering. They were merely given to ‘ameliorate’ side effects of the hormone ‘blockers’ that had been started earlier in the year. A supporting psychiatrist declared the doses were too small to constitute Stage 2 therapy, and these protestations were accepted by the presiding Justice Watts.
There was, however, opinion contrary to and unsupportive of those protestations. The doses given were, in fact, those recommended by international literature for the purposes of transgendering of post-pubertal males. And, literature reveals no support for the argument that small doses may ameliorate side effects of blockers.
Thus, the proceedings of the Court were based on a history of illegal prescription and administration of sex hormones to an underage youth, for reasons that were not validated by international practice. It might be expected that such illegality would have been examined by the Court, but it was not. It was passed over: stated reasons were accepted without question and the father was virtually commended for his vigilance.
The father, however, had a long history of domestic violence, and the poor youth, Imogen, and her sister, had existed in turmoil, descending into mental illness. The psychiatrist for the mother who opposed the administration of cross-sex hormones maintained gender confusion was but a symptom that had emerged from a panoply of prior psychiatric disease. He advocated a year of psychotherapy. Despite there being no childhood indications, the father’s psychiatrist argued for the primacy of gender dysphoria. Justice Watts aligned with the argument for hormonal transgendering. In the process, his rejection of the ideas of the mother’s psychiatrist became more ad hominen.
Strangely, it does not appear the Court wondered at the influence of the father over his natal son. Sigmund Freud might have asked if conflict had been avoided by the natal son’s adoption of the opposite sex. The possibility that psychotherapy which might have explored and ameliorated such tensions has, however, been precluded by Justice Watt’s preference for hormonal action.
The decision of the Court in Re Imogen 6 will be influential. Its conduct will raise doubts about impartiality. Its decision will mean only the bravest and wealthiest of parents and medical practitioners, will be game to pursue alternative, psychotherapeutic options for gender-confused offspring. It will be reasonable for parents to conclude there will be a twofold loss: the first being that of their child to hormones, the second being the loss of their own freedom, given current laws in the ACT ahd Queensland, and pending laws in Victoria and South Australia, hold the promise of gaol sentences for those who oppose hormonal therapy for gender confused children.
Bitterness in the Family Court.
Imogen is now 16 years and 9 months old. For 15 years she was known as Thomas, having been born a boy. For much of her life, she has existed in turmoil. Her father has been violent. He would ‘shout, swear and hit’ her mother and younger sister, and herself, if she tried to intervene. Her (now estranged) mother returned from a six-week secondment with her employment in October 2016, to a ‘war zone’ in which the children and their father were ‘screaming at each other’. The younger sister descended into mental illness.
So did Imogen, ultimately earning a list of psychiatric diagnoses from Major Depression, Social Anxiety with Panic attacks and Complex Post-Traumatic Stress Disorder to Parent-Child Relational Problem (due to her mother’s untreated post-natal depression, according to the violent father’s psychiatrist), and, as might be expected, addiction to the internet and school refusal.
Things worsened in 2018. The parents had separated in March 2017. School refusal increased, ‘it was difficult to get her out of bed in the morning’, she ‘cried under the sheets and ‘told her mother’ she was ‘lonely and depressed’.
Psychiatric medication was administered. Her relationship with her mother ‘started to deteriorate’. She became ‘aggressive and defiant’. And mother and two children underwent residential care.
The sister had regressed: by now ‘hiding in boxes; becoming non-verbal; starting to behave like a cat; petrified by loud noises, having severe phobias … running away from home and regressing to baby behaviour’. Not surprisingly, a doctor reported that ‘challenging family dynamics and (the sister’s) presentation severely impacts upon (Imogen)’.
Then, from October 6-12, the children ‘went on a holiday with the father and his then partner (who) was doing research on Gender minorities and their access to medical treatment’. On the very day of return, Imogen ‘told her mother that she wanted to be a girl’ and appeared to have ‘shaved her body hair’.
On October 15, the father informed the mother ‘Imogen has chosen a female name and prefers the female pronouns’. On October 25, Imogen went to live with the father. Psychological counselling continued.
In December 18, she was seen by a psychiatrist and a psychologist who did not diagnose Gender Dysphoria until February 2018. In the meantime, mother had remarried, and efforts to induce Imogen to schooling had stalled.
On March 21, the sister reported Imogen and her father ‘had been fighting’ and she (the sister) felt ‘helpless’ and had ‘started to self-harm’.
Later that month, at around 15 years and 4 months, Imogen ‘undertook sperm cryopreservation’ and, on April 16, entered Stage 1 of ‘affirmation’ therapy towards her elected gender identity, the administration of puberty blockers. On May 11, her psychiatrist ‘took a systemic history to determine if she met (diagnostic criteria) for Gender Dysphoria’. In Court, in August 2020, he declared she had.
On September 7, 2019, Imogen was prescribed a daily dose of 2 mg of Progynova (oestradiol valerate) which, according to the endocrinologist, was ‘aimed at ameliorating a side effect of Stage 1 treatment, and was not the commencement of Stage 2 treatment (the administration of cross-sex hormones to evoke external characteristics of the opposite sex).
On October 12, the father informed the mother ‘Imogen has commenced Stage 2 treatment’.
On November 5, an endocrinologist informed Imogen’s mother that he had prescribed oestrogens. On November 7, he informed the mother he would no longer ‘treat Imogen until the court made an order’.
On November 13, Imogen’s mother received a letter from an involved psychiatrist stating ‘the dose of oestrogen was not enough to be considered “phase 2” therapy’.
From December 2019, the father began to administer imported oestrogen ‘each day for the purposes of dealing with the side effects of Stage 1 therapy’, but according to the presiding Judge of the Family Court, ‘the evidence from the father is that Imogen is not using the drug to attempt to commence Stage2 treatment’.
On March 24, 2020, the mother sought orders for the Court to instruct the doctors to ‘cease providing hormone treatment (Stage 1 or 2)’. It would appear the mother did not learn of the imported doses until the hearing in August 2020.
On March 30, another psychiatrist was informed by Imogen and her father that oestrogen was being procured from overseas. That psychiatrist informed ‘others’ involved in Imogen’s care.
In May, Imogen was interviewed by psychiatrist Roberto D’Angelo, at mother’s request, pursuant to orders of the Family Court (Re Imogen 3. 2020. FamCA 395). Also in May 2020, in Re Imogen 4, when FCA considered who should be permitted to ‘intervene’ in its adjudication of Imogen’s mother’s opposition to Stage 2 therapy, and her insistence that Imogen was not capable of providing informed consent (Gillick competence), Justice Watts declared the proceedings ‘could involve the reconsideration of whether or not Stage 2 treatment (and possibly Stage 1 treatment) is non-therapeutic’.
This raised hopes that the ‘Short March’ of the Sexual Left through the FCA in pursuit of supremacy for the ideology of gender fluidity might have stalled: that some common sense remained.
On September 11, in Re Imogen 6, those hopes were dashed: Imogen was declared Gillick competent despite an acknowledged list of psychiatric conditions; the Court overruled the mother’s objections to hormonal therapy, and little consideration was undertaken as to whether hormones were ‘therapeutic’. Most discussion of Gender Dysphoria focussed on theories of causation, and statistics of de-transitioning.
Physiology was totally ignored: whether chemical castration, chemical lobotomy and the evoking of breasts were appropriate interventions for this psychologically disturbed youth was not considered.
The bitter pills.
Blockers have major effects on nerve tissue, from the brain to the periphery. They do not simply ‘block puberty’. Their use has been associated with cognitive effects in adults suffering from diseases, such as prostate cancer, which are fuelled by the sex hormones they block. They have been shown to alter the structural development of human brain, and have been proven, in sheep, to inflict sustained damage on the limbic system which integrates emotion, memory, cognition and reward into a kind of ‘inner world view’. Blocked sheep do not perform as well in mazes, are more emotionally labile, and have a demonstrable preference for the familiar, rather than the novel. In other words, they prefer the status quo and resist change, a proclivity relevant for someone who has become ‘familiar’ with the role of the opposite sex.
Blockers are alleged to provide more time for mature consideration of sexuality and procreation. However, they block the influences of both the primary centres for sexualisation near the midbrain, and the secondary centres, the gonads. How can a so-neutered youth ponder sexual identity and feelings with a damaged limbic system?
Blocking the testes blocks the formation of sperm, as well as the sexualising testosterone. Hence the collection of Imogen’s sperm before their administration. How well this process of chemical castration (to be augmented in a few months with oestrogen) was explained and comprehended is undocumented, merely assured by lawyers promoting their use.
Density of bone mass is increased during the process of puberty. Delaying puberty reduces that density, predisposing to later osteoporosis. There is no evidence that a small dose of oestrogen given to a ‘blocked’ natal male will reduce the propensity to bone thinning. As in The Monty, the dose needs to be Full.
The FCA judgement of Re-Imogen is but a summary of lengthy presentations and there is little comment on the lability of Imogen’s emotions after starting blockers except the short declaration that ‘tensions’ escalated between her and the mother.
Oestrogens further suppress the production of sperm and testosterone. How long it takes for female hormones (and blockers) to suppress the testes beyond recovery is unknown. In the meantime, oestrogens will evoke facsimiles of the female sex, such as breasts but, of course, cannot alter the female chromosomal pattern.
Oestrogens have also been shown to alter the structure of adult brains. Sex specific parts of the brain are organised in the first weeks of foetal life and await activation and by appropriate sex-hormones in puberty. From then, they appear to need sustenance from those hormones. The brain of an adult male deprived of testosterone and bathed in oestrogen has been found to shrink at a rate ten times faster than ageing, after only four months. Imogen had been taking them for almost a year at the time of the hearing, during what should have been a period of great teenage brain growth.
It is this structural effect on the brain by both blockers and oestrogen in the pursuit of psychological advantage that justifies the term ‘chemical lobotomy’. It hearkens back to the infamous period in which mainstream medicine colluded with the practice of surgical interruption of the forebrain for mental illness. Such was the uncritical adulation of the founder of this ‘therapy’ that he was awarded the Nobel Prize.
Imogen began to receive a daily dose of 2mg of oestradiol valerate from September 7, 2019. As declared in Re Imogen 4, the ‘rationale for moving quickly to prescribe the oestrogen’ was ‘the need to offset the harmful effects of stage 1 intervention on bone density’. The matter was raised again in Re Imogen 6 when it was argued this dose was aimed at ameliorating an effect of Stage 1 therapy and was not the commencement of stage 2 treatment’ which, of course, would have been illegal pending the approval of the Court.
In Re Imogen 6, it was reported the father told the mother ‘Imogen has commenced Stage 2 treatment’, but Judge Watts added ‘The assertion that Stage 2 treatment had commenced was incorrect’.
A psychiatrist joined the defence, writing to the mother to declare ‘the dose of oestrogen was not enough to be considered ‘phase 2’ treatment. And, later summarising the administration of imported oestrogen, Justice Watts declared, without clarification, ‘The evidence from the father is that Imogen is not using the drug to attempt to commence stage 2 treatment’.
Despite protestations that 2 mg of Progynova a day does not comprise Stage 2 therapy, international guidelines declare 1-2 mg to be inductive of puberty in post-pubertal males seeking to transgender to females. The dose may be increased to 6mg per day, according to effect.
Justice Watts was ‘reassured’ Imogen’s father had taken ‘responsibility for administering’ her illegal medication and was ‘limiting her to 2 mg a day’ and that a hospital had not ‘raised any red flag arising from Imogen’s blood tests in relation to the level of oestrogen that Imogen is currently taking’.
Regrettably, Justice Watts did not identify the nature of the blood tests, or their prescriber. The tests could have been assuring the absence of testosterone in the process of transgendering, as well as the level of administered oestrogen.
Identification of the requesting doctor (s) would have revealed something of the collusion between doctors and the father in the illegal administration of imported steroids to an under-aged and vulnerable youth. The lack of judicial interest in this underlying violation challenges respect for the Family Court.
It is strange that Justice Watts emphasised the importance of evidence in various parts of his judicial summary but apparently failed to seek it with regard to the claims for the use of oestrogen. A superficial Google search would have confirmed the transgendering dose of 2 mg a day. And, deeper searching would have failed to find any justification for the claim that a small dose would reduce the impact of blockers on density. It may be asked why various doctors arguing the dose was too small to transgender but sufficient to protects bones, failed to produce supporting literature. Doing so could have helped the reputation of FCA.
The bitter fight.
The psychiatrist for the mother, Roberto D’Angelo, was outgunned in the Court, confronted by the father’s barrister, the Australian Human Rights Commission and the Independent Children’s Lawyer. Essentially, he argued gender dysphoria was a new symptom which had emerged from the panoply of established psychiatric disorder with help from social media.
One opponent argued hitherto unsuspected gender incongruity is emerging in increasing numbers due to ‘developments in society and in medicine’ which are ‘leading to greater awareness and understanding’. On the face of it, these arguments appear similar: vulnerable teenagers are susceptible to societal influences, but the opponent was adamant that ‘social contagion’ was not relevant.
Much energy was then expended to discredit the conclusions of US researcher, Lisa Littman, that the rising phenomenon of ‘rapid onset gender dysphoria’ in vulnerable teenage girls was influenced by contagious social influences. Fulsomely, the opponent denied Littman’s simple conclusion, declaring current changes ‘in gender demands … increased knowledge, understanding and self-reflection and other factors more commonly play a part’.
Whatever that meant appears to have had greater appeal to Justice Watts who was able to declare ‘there is no actual evidence that Imogen has been infected by contagion as a result of involvement with the internet or social media’. Apparently the Judge found no relevance in all the testimony of fights over Imogen’s addiction to her computer.
Also, accepting Imogen’s mother was ‘suspicious’ of a link between the ‘weekend’ (more like a week if the Judge did the maths) Imogen spent with her father and his gender-researching girlfriend, and her ‘coming out’ on the day of return, the judge propounded ‘there is no evidence’ the gender researcher ‘said anything … that would have unduly influenced Imogen’.
Yet the judge was quick to find ‘evidence’ of an alleged deficiency in Roberto D’Angelo’s analysis of a major research publication from Sweden that had concluded there was a marked increase in suicidality in transgendered adults. From listening to the argument between D’Angelo and the father’s barrister on interpretation of some statistical data in the article, the learned judge ‘was satisfied Dr D’Angelo had not properly analysed the table in the report upon which he based his claim’.
The Judge’s predisposition for accuracy was, however, challenged by his erroneous reference to the above paper in the Court summary. The paper was the one described below. Justice Watts referenced another, from Belgium. The question must be asked: did the Judge examine the papers himself, or merely relay rhetoric from the opposing lawyer?
The ‘Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden’ had involved 324 sex re-assigned persons from 1973 to 2003 and had concluded there was a 19 times increased ‘hazard rate’ for suicide compared with controls. It was authored by researchers from Karolinska Institute and Gothenburg University and had received no significant disagreement until that proffered by the lawyer from the Australian Human Rights Commission, supported by Justice Watts.
Similarly, in argument with the Human Rights lawyer over possible reasons for the loss of transgendered people to follow-up in another study, Justice Watts declared ‘I reject Dr D’ Angelo’s claim that the 30 per cent loss to follow up may consist of people who regret their transition’. The judge produced no evidence to support his sweeping conclusion (how would anyone know the reason people refused to co-operate?). Nor did the judge provide a reference to the paper.
Despite the hours of hearings and the need, therefore, to summarise succinctly, the judge saw fit to emphasise the submission by the Independent Children’s Lawyer that Dr D’Angelo displayed ‘rigid unwillingness’ to accept the new symptom of gender dysphoria as ‘a driver’ for her long standing anxiety.
In his conclusions, Justice Watts declared he had ‘reservations about the basis and practicality’ of Dr D’Angelo’s recommendations for psychotherapy (rather than hormonal intervention)’. The Judge declared he did not accept the argument that Imogen does not have gender dysphoria. Nor did he not accept Dr D’Angelo’s ‘conclusions about how Imogen presented to him’, declaring Dr D’Angelo ‘presents as an advocate for an alternative approach to the treatment of adolescents with Gender Dysphoria’. Earlier, the Judge had asserted his belief that the regime of ‘affirmation therapy’ had been accepted by the majority of the medical profession and represented the ‘orthodox middle’ of therapeutic options.
As to the impracticality of organising regular psychotherapy for one year, as suggested by Dr D’Angelo, Justice Watts appears to be unware of the practical difficulties associated with a life-long dependence on medical supervision (often including mental issues) for those transgendering with hormones.
Without provision of any supporting evidence, and in contradiction to presentations of the father’s violent nature and sustained family unhappiness, Justice Watts was able to pontificate ‘Imogen has a robust relationship with her father in whom she has a great deal of trust and will continue to have a meaningful relationship with him’ Someone with less prophetic zeal might have looked more closely at the relationship of the disturbed natal male with her father. It is surely not too Freudian to wonder at the power of the father over the natal son? Did Imogen find being a female resulted in less conflict? Did she find her father’s toxic masculinity so unattractive she decided to join the other side? Was joining the other side the best way to ensure acceptance by the father/gender researcher dyad? Furthermore, it is surely not pedantic to acknowledge reports in international literature of the possibility of personality disorder in parents of children confused over gender identity?
One way or another, Justice Watts has banned the opportunity for psychotherapy that might have unravelled some of the tragedy, condemning her to hormones.
The bitter end.
There may be a positive outcome from Imogen 6: the need for court authority for prescription of such drugs is emphasised if there is dispute between parents. Conversely, the failure of the Court to criticise the under-age prescription of oestrogen that had preceded its hearing by almost a year, indicates the Court does not really take such things seriously. Given the Australian Guidelines promulgated by the Melbourne Children’s Hospital have expressed no age limits, the growing argument that children on blockers should be allowed to develop puberty at the same time as their peers, and the claim that forced delay of puberty to 16 years worsens psychological stress and predisposition to osteoporosis, it would appear only a matter of time before limitations are lifted.
Given recent legislation in the Australian Capital Territory that criminalises parental opposition to hormonal therapy for a gender confused child, and prescribes 12 months in gaol for miscreants, it is likely that opposition to ‘affirmation’ will decrease. Only the bravest of parents and doctors (and the wealthiest) are likely to commit themselves to the battle.
Finally, it was disappointing that Justice Watts went nowhere near questioning the therapeutic role of hormonal therapy. In corollary, it was painful to perceive an apparent intellectual and emotional abdication of the Court to ‘affirmation therapy’. From the transcripts of many hours of discussion, Justice Watts selects excerpts that amount to ad hominem attack on Roberto D’Angelo for proposing an ‘alternate’ therapy for gender dysphoria: one based on psychotherapy rather than chemical castration and lobotomy. Sadly, there now threatens a fusion of powers: political, legal and medical to oblige that invasive experimentation.
Dr John Whitehall has written several articles for Quadrant on childhood gender dysphoria, most recently ‘Banning Alternatives to Child Gender Experiments‘ in our January issue
 Whitehall J. The Short March of gender fluidity through the Family Court. Quadrant. August 2020.
 Hembree et al Guidelines on Gender-Dysphoric/Gender-Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869–3903.
 Smith KP et al. Gonadal Suppressive and Cross-Sex Hormone Therapy for Gender Dysphoria in Adolescents and Adults. Pharmacotherapy 2014;34(12):1282–1297) doi: 10.1002/phar.1487
 D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry. 2018:1-4.DOI:10.1177/1039856218775216..