Why the medical profession abandoned good practice for the depathologization movement

Guilt over the pathologization of homosexuality led psychiatrists to turn a blind eye to the failures of gender affirming care

As a doctor and psychiatrist reflecting on the lessons of the Cass Review, I feel a deep sense of shame that my profession and specialty did not prevent the ongoing tragedy of gender affirming care. As the final report makes clear, medical leaders almost universally stood aside while a small group of committed ideologues ignored or bypassed all the usual ethical and institutional safeguards to force their ideology on a group of highly vulnerable children using a corrupted model of medical treatment. 

Sacrificing patient health in pursuit of rights

Among the hundreds of pages of errors and wilful misbehaviour documented by the Cass Review it is easy to miss, but page 13 contains one of the most important paragraphs:

• It often takes many years before strongly positive research findings are incorporated into practice. … Quite the reverse happened in the field of gender care for children.

Any doctor who values the reputation of the medical profession should be troubled that across the western world, multiple centers aspiring to medical excellence constructed an industry of life-altering interventions with no convincing evidence of benefit and significant known harms, all in less time than it usually takes to test whether an individual treatment works.

I have described elsewhere how the clinical guidelines/standards for gender affirming care abandon the medical model in order to pursue the political goals of trans rights activists (see scientific article and newspaper opinion), prioritising the right to gender self-identification over the duty to promote patient health. In order to prevent this from happening again it is equally important to understand why medicine's gatekeepers abandoned their principles for such a dubious goal.

Part of the answer is that there was an organized, strategically coordinated campaign by activists, including activist clinicians, to influence medical decision-makers in order to bypass unfavourable public opinion. For those interested there is a Thomson-Reuters report compiled for iglyo which lays the strategy out in detail. However, in most cases it appears that gender-affirming care was permitted, indeed promoted, by senior medical leaders who must have known what they were doing, but have not been held accountable.

Psychiatry, homosexuality, and the depathologization movement 

The main reason medical leaders sacrificed patient rights and abandoned medicine's usual safeguards for gender affirming care was their uncritical acceptance of the rationale of the depathologization movement (see the legal strategy laid out by GATE). This movement argues that applying the regular medical model to gender dysphoria causes the pathologization of gender identity.

It is understandable that gender diverse patients and their supporters might experience the diagnosis of gender dysphoria as the cause of their distress, rather than the recognition of a clinical syndrome requiring assessment. It is unacceptable that any doctor would agree not to investigate pathological causes of gender dysphoria in order to avoid acknowledging the reality that such causes exist. It is unthinkable that any medical decision-maker that endorsed gender affirming care be allowed to escape responsibility for the harms caused by their decisions.

The reluctance of the psychiatric profession to stand up to the depathologization movement is largely due to historical guilt over the pathologization of homosexuality, which was classed as a mental illness until the mid-1970's. However, while no-one has ever provided evidence that homosexuality is the result of mental illness, it is undeniable that some cases of non-traditional gender identity are caused by severe mental illness. (See the case of Daniel Paul Schreber for a famous example where bipolar disorder caused the delusion that a male judge was being turned into a woman to repopulate the earth.)

Due to the influence of the depathologization movement, the WPATH, AusPATH, and the whole circular facade of gender affirming standards and guidelines assume without evidence that mental illness plays no role in the development of non-traditional gender identities. They do not address known examples of transgenderism caused by severe mental illness, such as Schreber's case; or other psychopathological processes, like trauma from sexual abuse, personality pathology, or mood disturbance. They simply note the high comorbidity of gender dysphoria with other types of mental illness, and assume that some other service will accept the responsibility of detecting and addressing the comorbidity that is missing from their model.

Effects of the medical profession's failure to address the errors of the depathologization movement

Medical leaders' acceptance of the depathologization movement's demand that no pathological cause of gender identity can be considered in the assessment and treatment of gender dysphoria has had multiple harmful effects, all clearly outlined in the WPATH and AusPATH endorsed documents and the Cass Review.

First, this acceptance prevents the diagnosis and treatment of frank mental illness in patients presenting with gender dysphoria, a process described as diagnostic overshadowing by Cass. Second, it prevents the consideration of any alternative modes of treatment. Neither the WPATH nor the AusPATH realistically discuss alternatives to gender affirming care, and neither provide any real description of the management of patients after desistance or detransition.

Finally, by assuming that all gender diverse identities are simply variations of normal development, by definition and without the possibility of question, the WPATH/AusPATH endorsed models erect the framework of a medical protocol around a meaningless construct. Gender identity is never formally defined by the WPATH standards, which treat it as the arbitrary combination of characteristics reported by individual patients, unconstrained by the need for stability, coherence, or even an understandable connection with traditional experiences of gender.

This satisfies the political goal of the trans rights movement, that self-reported gender identity be entirely unconstrained, at the cost of abandoning the medical model which cannot safeguard patient health without the valid and reliable diagnosis of disease.

The medical profession must acknowledge and address the failures revealed by the Cass Review

I am proud to be a doctor and a psychiatrist, because these disciplines have done so much to improve the human condition by continually striving to increase our understanding of human nature, health, and illness. The corruption of the medical model by a political movement revealed by the Cass Review demands the profession admit to its failures and act to correct them.

In my opinion, the appropriate response to the Cass Review would be the immediate announcement of the end of gender affirming care. The existence of thousands of patients, supporters, and staff engaged with the model, and the scale of the gender affirming infrastructure entrenched within health bureaucracies, presents practical difficulties, but there are a number of feasible first steps that must be taken to maintain public confidence in the integrity of the medical profession.

The most urgent need is for health authorities to immediately impose adequate clinical governance over services that have effectively been operating without public oversight. After up to a decade of practice, Australian gender services have established no routine data collection or reporting, with the result that no-one knows how many patients have been affected, the number and variety of interventions applied, or the harms they have suffered from gender affirming care.

The failure to address desistance and detransition is an unforgivable gap in the gender affirming model. According to the anecdotal evidence that is all that is available, by the time patients realise they no longer want to transition, they have often been alienated from friends and family, leaving them entirely dependent upon the support of gender services. Fear of abandonment forces many to remain with gender services despite their doubts, while actual abandonment often causes severe distress to those who finally leave.

Finally, while an Australian enquiry modelled on the Cass Review is absolutely necessary, it is likely to confirm what we already know about the failures of the past by replicating the UK results. An ambitious enquiry will aim to prevent future failures by considering the following additional questions, in order to identify the root causes of the current situation:

• Why did gender services expand so rapidly despite the lack of evidence that they would benefit patients?

• Who were the decision-makers that endorsed the creation and expansion of gender services?

• What additional safeguards are necessary to ensure that medical decision-makers are not influenced by political goals?