While countries around the world restrict gender medicine for children, Australian kids continue to have easier access.
When did children become consumers of irreversible medical treatments?
I spent Saturday in Adelaide listening to international clinicians, researchers and legal experts discuss one of the most contentious areas of modern medicine: the medical transition of children experiencing gender distress.
The Coalition Advancing Scientific Care (CASC) conference covered everything from the developing adolescent brain to the long-term outcomes of medical transition and the prospect of future litigation against gender clinicians.
But it was one observation from Irish psychotherapist Dr Stella O’Malley that stayed with me.
Healthcare is not consumerism.
We appear to have confused patient-centred healthcare with the idea that patients should receive whatever treatment they request.
And when the patient is a child, the consequences of that thinking become considerably more troubling.
Consider a teenage girl suffering from anorexia nervosa who approaches her doctor requesting Ozempic.
She explains that she is deeply distressed by her body, believes losing weight will improve her psychological wellbeing and insists she understands the risks.
Imagine the doctor agrees, and several months later she reports feeling happier, more confident and grateful that someone finally listened to her.
Would we consider this good healthcare?
Of course not. We would question the judgement of a clinician who prescribed weight-loss medication to an underweight teenager with an eating disorder, irrespective of how satisfied she reported feeling afterwards.
Her distress would be genuine, as would her belief that changing her body would resolve it.
But neither establishes that the treatment was medically appropriate.
Anorexia and gender dysphoria are different conditions, but the example illustrates a fundamental principle of medicine: a patient’s conviction about what will make them happier is not sufficient justification for medical intervention.
Yet in paediatric gender medicine, children and adolescents may access puberty blockers and cross-sex hormones, treatments with significant implications for physical and cognitive development, sexual function and potentially fertility.
Puberty blockers in particular have been sold to desperate parents as a myth that they are safe and reversible.
And these decisions are being made by children whose brains are still developing.
Professor Sallie Baxendale, a clinical neuropsychologist from University College London, addressed the conference on adolescent brain development and informed consent.
As psychologists, we understand that the prefrontal cortex and associated neural networks involved in planning, impulse regulation, evaluating risks and anticipating long-term consequences continue developing into early adulthood.
A teenager may be intelligent, articulate and utterly convinced that medical transition is the answer to their distress.
But understanding that infertility is a possible consequence is not necessarily the same as appreciating what infertility might mean to their future adult self.
We recognise children’s developmental limitations in countless other areas of life.
We restrict their access to alcohol, gambling and cosmetic procedures because we understand that some decisions carry consequences beyond their capacity to fully anticipate.
Yet when it comes to medical interventions that may permanently alter their bodies, we are prepared to accept that a child’s expressed wishes forms a central part of the justification for treatment.
Even if the law recognises that some minors can demonstrate sufficient maturity to consent to medical treatment, legal capacity and clinical appropriateness are entirely different questions.
Even if a child were deemed competent to consent, they cannot make an inadequately evidenced intervention safe or effective.
All international evidence is pointing to the fact that medical transition for gender dysphoria is a failed intervention and a dangerous experimental procedure when it comes to our kids.
Following the independent Cass Review, NHS England ended routine prescribing of puberty blockers for children experiencing gender dysphoria.
In March this year, it also paused new prescriptions of masculinising and feminising hormones through its children’s gender service while reviewing their routine availability.
Sweden and Finland have also adopted more cautious approaches, placing greater emphasis on psychological assessment and restricting access to medical intervention.
Meanwhile, Australian practice remains inconsistent. Queensland has restricted new patients under 18 from commencing puberty blockers and gender-affirming hormones through its public hospital services, while treatment remains available elsewhere.
Why should Australian children be exposed to interventions that major overseas health authorities have decided require substantially greater caution?
Another confronting issue raised at the CASC conference was how we measure treatment success.
A young person reporting that they feel happier following medical transition is meaningful, but it cannot be the sole measure of clinical effectiveness.
Medicine must examine long-term psychiatric outcomes, physical complications, fertility, sexual functioning and objective quality of life measures, rather than relying on initial satisfaction or individual testimonials.
Surely, when the proposed treatment may permanently alter a child’s body, the burden should fall on those providing it to demonstrate that its benefits justify its risks.
Emeritus Professor Patrick Parkinson and barrister Belle Lane also addressed the prospect of an avalanche of litigation against gender clinicians.
What happens when young adults who underwent medical transition as children begin questioning whether they were adequately assessed, properly informed about the risks or offered alternative forms of support?
Medical negligence requires proof of a breach of duty and resulting harm.
But I suspect litigation involving childhood medical transition could become one of the defining medical accountability issues of this generation.
History is littered with examples of medical confidence running ahead of evidence.
Thalidomide remains a devastating reminder of what can happen when treatments are embraced before their risks are adequately understood.
Medicine cannot afford to become captive to political ideology, social trends or the belief that compassion requires clinicians to agree with a patient’s preferred treatment.
Children experiencing gender distress deserve compassionate care, comprehensive psychological assessment and support.
But compassion is not measured by how readily a clinician agrees to alter a child’s body.
Sometimes the most responsible thing a healthcare professional can do is say no.
Because children are not consumers purchasing a service. They are developing human beings who depend on adults to exercise the judgement they are still acquiring.
And our responsibility is not simply to relieve the distress of the child standing before us today, but to protect the interests of the adult they will one day become.
