Statement on Four Corners report “Blocked: The battle over youth gender care”
On Monday, 10 July 2023 at 8.30 PM AEST, the ABC's Four Corners program broadcast Blocked: The battle over youth gender care, reported by Patricia Karvelas, produced by Lesley Robinson and researched by Carla Hildebrandt (hereinafter: the producers). At the start of the broadcast, Ms Karvelas claimed she wanted ‘to understand why medical interventions for transgender young people have become such a battleground. Is it right to provide puberty blockers and hormones? Is enough caution being exercised? And is this model the life saver its supporters say it is?’ Despite the ostensible neutrality of Ms Karvelas's professed intent, the LGB Alliance Australia is gravely concerned by the framing, omissions, and distortions of this 56-minute broadcast, and hence by its potential to mislead the public on matters which, notwithstanding their emotional volatility, demand to be treated with due regard for their social and ethical complexity.
The following points of criticism and query pertain to Blocked and an article, Controversial research pulls Westmead children's hospital into centre of fight over gender care (by Karvelas, Robinson and Hildebrandt), which was published on the ABC website in conjunction with the Four Corners report.
Framing
Blocked framed the debate on medical interventions as one between right-wing extremists on one hand, and medical institutions, parents of ‘transgender kids’ and ‘transgender kids’ on the other. In one display of this bias masquerading as context, footage of Donald Trump and of the neo-nazis who imposed themselves on the Let Women Speak event in Melbourne earlier this year was shown immediately after and in stark contrast with footage of a grieving mother, as if to suggest these represented the two sides or two extremes of the debate.
That the report included interviews with such critical figures as Dr Jillian Spencer does little to convince us that balance was genuinely sought, since Dr Spencer’s photo in the accompanying ABC Online article is captioned: ‘Dr Jillian Spencer has spoken at rallies with an anti-trans activist.’ The ‘anti-trans activist’ being referred to is, we infer, Kellie-Jay Keen (AKA Posie Parker), women’s rights campaigner and organiser of the Let Women Speak events, of whom footage is included in Blocked between the clips of Donald Trump and the neo-nazis, and later in a clip with Dr Spencer at a Let Women Speak event. The portrayals of these women can only be described as an attempt to insinuate guilt by (visual) association, presenting them as far-right adjacent if not on the far right.
A responsible reporter would not have indulged in such emotive expeditions (Trump, neo-nazis) and distortions (Kellie-Jay Keen, Jillian Spencer), but would have forgone them for the sake of clarity on the pertinent social, medical, and ethical issues.
Throughout Blocked, Ms Karvelas and others also refer to 'transgender young people' and 'transgender kids', terms among others which confer a stability, coherence and concreteness upon cross-sex identification and thereby implicitly endorse the view that 'being trans' is an inborn trait. If, as Ms Karvelas asserted, her aim was to understand why medical interventions for trans-identifying young people have become a battleground, it would have behoved her first to understand the points of conflict so that she might in her reportage occupy a genuinely neutral standpoint on the dispute.
Her use of such concretising language as 'transgender kids' and 'transgender young people' (as opposed to the more neutral ‘trans-identifying kids’ or ‘trans-identifying young people’) subtly forecloses a core debate of the so-called gender wars, namely, whether cross-sex identification is the expression of an innate and unchanging essence, or if it is not rather a transient psychological response to lived experience, which includes the experience of one’s own body, the social expectations and interpersonal abuses to which one’s body is or may be subject, and the inner turmoil to which these expectations and experiences can give rise.
At best the producers of Blocked are ignorant of the content of the disputes on which they are reporting, at worst theirs is a partisan standpoint which they lack either the insight to recognise or the honesty to declare.
Omissions
Blocked failed to:
Emphasise the difference between suicidality (i.e., suicidal ideation) on one hand and suicide attempts and actual suicides on the other [1], concepts which a lay audience might easily confound.
Contextualise suicidality appropriately with reference to the relevant background population, which is not the general population but the population of teenagers and specifically the population of teenagers exhibiting complex psychological comorbidities.
Probe the ideological integrity of such narratives as:
that one can be born in the wrong body;
that a person can ‘be born with a boy’s body’ but have ‘the heart and mind of a girl’ (or vice versa);
that a boy’s dislike of ‘rough housing’ and failure to observe social codes of attire be taken as evidence he is in fact a girl born in the wrong body.
Go into detail about the change of course in Finland, Sweden and the United Kingdom [2, 3], and how the experiences in those countries apply or might apply to the Australian context.
Discuss factors or conditions which have been acknowledged to co-occur with cross-sex identification, including but not limited to an autism spectrum diagnosis [4] and other neurodevelopmental and psychiatric diagnoses [5].
Discuss the fact that gender non-conforming children are highly likely to be same-sex attracted and grow up to acknowledge themselves in adulthood to be either lesbian, gay, or bisexual.
Distortions
The Cass Report
Blocked referred to the case of the UK’s Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust. The service has been closed down in consequence of an independent review (ongoing) chaired by esteemed paediatrician Dr Hilary Cass. Yet Blocked did not engage with the contents of the report at even a superficial level, nor did the producers apparently seek to interview Dr Cass; instead, comments from psychologist Dr Dianna Kenny and psychiatrist Professor Ian Hickie on the Tavistock situation were provided from their respective viewpoints. The following summary of the GIDS/Tavistock situation by Prof Ian Hickie was presented without challenge:
What went wrong at the Tavistock clinic is to get stuck in one particular point of view. So what happened? People working there simply said it's more complex and we need to have services that understand that complexity and also respond in real time. We can't just in a cookie cutter way, do the same thing for every kid. It was not about that the approaches were intrinsically wrong. It was bad management of the complexity of the kids coming forward. And I think there's an important learning out of the Tavistock, how to do it wrong.[6]
A cursory glance at the Summary of Dr Cass’s interim report (the Cass Report) calls the accuracy of Professor Hickie’s statement into doubt. The following items are drawn directly from that Summary (p. 14ff., emphasis added):
1.5 The Review is not able to provide definitive advice on the use of puberty blockers and feminising/masculinising hormones at this stage, due to gaps in the evidence base; however, recommendations will be developed as our research programme progresses.
1.7. At primary, secondary and specialist level, there is a lack of agreement, and in many instances a lack of open discussion, about the extent to which gender incongruence in childhood and adolescence can be an inherent and immutable phenomenon for which transition is the best option for the individual, or a more fluid and temporal response to a range of developmental, social, and psychological factors. Professionals’ experience and position on this spectrum may determine their clinical approach.
1.8. Children and young people can experience this as a ‘clinician lottery’, and failure to have an open discussion about this issue is impeding the development of clear guidelines about their care.
1.10. The mix of young people presenting to the service is more complex than seen previously, with many being neurodiverse and/or having a wide range of psychosocial and mental health needs. The largest group currently comprises birth-registered females first presenting in adolescence with gender-related distress.
1.14. Primary and secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.
1.16. Another significant issue raised with us is one of diagnostic overshadowing – many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be overlooked.
1.24. A lack of a conceptual agreement about the meaning of gender dysphoria hampers research, as well as NHS clinical service provision.
1.26. Internationally as well as nationally, longer-term follow-up data on children and young people who have been seen by gender identity services is limited, including for those who have received physical interventions; who were transferred to adult services and/or accessed private services; or who desisted, experienced regret or detransitioned.
Professor Hickie’s assessment that the closure of GIDS was not about the approaches being intrinsically wrong should not have gone unchallenged by Ms Karvelas, given that the Cass Report identified gaps in the evidence base (1.5, 1.26), a lack of professional consensus at multiple levels about the significance of cross-sex identification (1.7), a lack of conceptual agreement about the meaning of gender dysphoria (1.24), changes in the epidemiology of cross-sex identification (1.10), and diagnostic overshadowing of the complex needs children and young people presenting to the service (1.16).
In all these respects, Hannah Barnes’s book Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children provides illuminating detail. As regards diagnostic overshadowing specifically, LGB Alliance Australia must underscore Barnes’s observation that ‘a significant number of clinicians were also increasingly worried that sexuality, like much else, wasn’t being adequately explored in assessments.’ (p. 159) Barnes notes that ‘[s]ome young people themselves would be repulsed by the fact that they were same-sex attracted’ (p. 160) and that one clinician ‘came to feel that GIDS was performing “conversion therapy for gay kids”. It’s a serious claim. Some clinicians have relayed how there was even a dark joke in the GIDS team that there would be no gay people left at the rate GIDS was going.‘ (p. 161)
Blocked did not treat sexuality as a topic at all. The sole reference to it was made by Dr Jillian Spencer: ‘I worry about the harm to children and of concern is the knowledge that it is much more common for children who later will be gay or lesbian to show cross-sex identification and gender dysphoria in childhood. So, there is that worry there that we're changing the trajectory of those children.’
We also query the utility of Professor Hickie’s description of a medical treatment as ‘intrinsically wrong’ (or not, as the case may be). The rightness or wrongness of a medical treatment, therapy or intervention is generally not part of its intrinsic character but is determined by a range of factors including but not limited to the diagnosis, prognosis, patient values, competence to consent, implicit or institutionally articulated medical and public ethical frameworks, and the calibre of the evidence which informs all these factors.
Many treatments which historically were deemed right (e.g., thalidomide for morning sickness, electric aversion therapy for homosexuality) are, for diverse reasons, no longer so deemed; the amputation of a foot is right when the foot is gangrenous, wrong when it exhibits no pathology whatever; the rightness or wrongness of undergoing chemo-, immuno- or radiotherapy to treat a patient’s cancer depends on the nature of the cancer, its stage, the prognosis, and the patient’s values and preferences. But if we are to allow Professor Hickie’s term ‘intrinsically wrong’ to be used, then in view of the issues around gender affirmation identified in the Cass Report and referenced above, few models of ‘care’ would seem to qualify for that designation so well as gender (i.e., cross-sex) affirmation.
Suicides
One of the ideas which remained unchallenged in Blocked was that trans-identifying young people are at unusual risk of committing suicide (we have already pointed out the problem of not differentiating suicidality from suicide, and of discussing suicidality without reference to an appropriate comparator population) and that this is a reason to affirm their cross-sex identification. We are not suggesting that it would have been appropriate for Ms Karvelas to challenge this narrative in a direct manner with those parents who invoked or alluded to it. But, given it is a widely dispersed and contentious claim, it would have been appropriate for Ms Karvelas to identify and scrutinise the evidence on which it is based, not least because suicide, as Mindframe Australia points out, ‘arises from an interaction between many vulnerabilities and risk factors in a person’s life’ and ‘may also be influenced by social and economic circumstances and differences between cultures and individuals’ experiences within society.’
Not only did the producers fail to assume a neutral and critical standpoint on this claim, but they endorsed it in their irresponsible reporting of the story of Noah O’Brien, a young female who identified as a boy and took her own life after prolonged personal crisis. Blocked failed to distinguish at least two issues in Noah’s story. Firstly, and most importantly, a confused, self-harming young person’s lack of access to timely mental healthcare; secondly, the purported failings of Westmead’s gender service. The failure not only to treat these distinct issues separately but, moreover, the failure do so in the context of a report which had already cast doubt on the reluctance of Westmead clinicians to embrace the gender affirmation model, gives the strong impression to viewers that this young person’s suicide resulted from a lack of access to gender-affirming care specifically, rather than to psychological and psychiatric care generally. Here as elsewhere but less subtly, Blocked forecloses that core debate of the so-called gender wars, and one which (as the Cass Report makes clear) has not even been resolved by professionals, ‘about the extent to which gender incongruence in childhood and adolescence can be an inherent and immutable phenomenon for which transition is the best option for the individual, or a more fluid and temporal response to a range of developmental, social, and psychological factors.’ [7, p. 16] This debate is inseparable from questions about the ethics of gender affirmation.
The producers of Blocked certainly had a duty to respect and treat with compassion the personal accounts and experiences of Noah's family, of the families of other trans-identifying young people, and of the young people themselves; but they also had a duty to articulate the complexities—personal, social, medical, ideological, political and ethical—which attend trans-identification and its medical affirmation in young people. In this regard, Blocked fails utterly, and the failure is all the more alarming and inexcusable given Blocked is a late arrival on this issue and the producers therefore had at their disposal a wealth of domestic and international reportage, scholarship, and the institutional findings of the Cass Report, from which they might have taken their lead when investigating and reporting on the situation in Australia. We hope that the ABC will take account of the issues we have outlined above and improve its coverage of these important topics in future.