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A clinic at a leading Sydney hospital has become embroiled in a war over how to help kids in distress about their gender, grinding services for new patients to a halt as waiting lists blow out.
Only three new patients have been seen at Westmead children’s hospital’s gender clinic this year due to a lack of staff and a string of resignations. Last year, they saw 88 new patients.
Despite the clinic receiving an annual budget of $1.5 million, they have very small staff numbers.
Some staff have left following the publication of controversial research endorsed by the hospital hierarchy. The research was initiated in 2013 and current frontline staff from the gender unit were not involved.
The research is being weaponised by anti-trans activists and proponents of alternative forms of gender care.
This clash of science, research, and ideology is part of a polarising and sometimes toxic debate over the gender “affirmation” model that’s playing out around the world.
Gender-affirming care can include puberty blockers to suppress puberty for young people distressed by their changing body. In some cases, this is followed by cross-sex hormones to allow people to transition into the gender they identify with.
Transgender health expert Sam Winter, who works in the School of Population Health at Curtin University, argues this model of care is now under “existential threat”.
“It’s getting rather nasty,” Mr Winter said.
Anna resigned late last year after working for six months as a clinical psychologist at the Westmead gender clinic. She says she didn’t feel supported by hospital hierarchy to provide gender-affirming care.
“The [gender clinic’s] core team was incredibly gender-affirming and supportive, but it felt like everyone else was doing the bare minimum,” Anna told Four Corners.
“I felt that the environment was very difficult.
“I think one of the main issues was the long wait list, the lack of staff.
“Our model of care was being developed to become a better, improved model of care. But it was never finalised, no action was ever taken with that. We were told that we had received funding for more staff, which would’ve been fantastic.
“But while I was there, there was nothing, no change, same huge wait-list”.
In December last year, Westmead had just 145 patients on its books, compared with 1,095 patients at Melbourne’s gender clinic and 922 patients at Queensland’s gender service.
Westmead’s clinic now has 115 patients on its waiting list.
Sydney Children’s Hospitals Network, which oversees Westmead, said it “continues to provide holistic, culturally safe and affirming care to current patients”.
In 2021, the NSW government allocated an annual budget of $1.5 million to open a new gender hub for under 25-year-olds. The service was to be run by Sydney Children’s Hospitals Network and another health partner.
But after two years and more funding, the service is yet to open.
NSW Health has told Four Corners it was “under development”.
Referrals to Australia’s publicly funded gender clinics are ballooning.
Queensland Children’s Hospital has more than 600 patients waiting for a first appointment, while the Perth Children’s Hospital has more than 150.
Heartbreak and distress
Unlike other clinics around the country, Westmead children’s hospital deprioritises children on its wait list who are well advanced into puberty or post puberty.
The service also does not provide cross-sex hormones to children, leaving families with the difficult decision of leaving kids on puberty blockers longer, or navigating expensive and difficult private pathways to help their children transition.
Renee Willcocks was desperate to get help for her daughter Brock from Westmead’s gender clinic.
“They were so lovely on the phone. But it was very heartbreaking,” Renee said.
She said she was told that Brock could go on a waiting list but that she wouldn’t be prioritised.
“It was because Brock’s voice had already broken. So being a 13-year-old, they couldn’t help us,” Renee said.
Puberty was distressing for Brock. The upbeat and extroverted kid became withdrawn and depressed.
“I hated my body. I hated being a male. I would just cry my eyes out. I couldn’t stand seeing myself in the mirror,” Brock said.
Another NSW Health-run clinic, Newcastle’s Maple Leaf House, did accept Brock.
“I broke down and cried. It was such a relief,” Renee said.
A psychiatrist diagnosed Brock with gender dysphoria – psychological distress experienced by those whose gender identity doesn’t match their sex assigned at birth — and she started receiving puberty blockers. Clinicians explained the medication may be associated with reduced bone density.
Some medical professionals say this approach is too extreme and carries risk.
They instead push for what’s called “watchful waiting”, arguing that with psychotherapy and the passage of time, many gender issues will resolve.
This is strongly refuted by most gender doctors. The medical professionals running Australia’s top state funded gender clinics in Melbourne and Brisbane have told Four Corners the gender-affirming model is a life saver and tearing it down would put young people at extreme risk.
Later this year, Brock wants to start hormones to look more feminine. Daily pills or patches of estrogen would slowly soften her features and develop breasts and hips.
“I always get asked, ‘Is this something you’re sure you want to do?’ And a lot of, ‘Are you sure?’ Or it’s, ‘Just checking in, do you still want to do this?’,” Brock said.
“The amount of times I’ve had to say, ‘Yeah, I want this. I need this badly’.
“I didn’t wake up one day and be like, ‘Yeah, I’m trans’. No, it was years of dysphoria, self-hate.”
Transgender health expert Jeremy Wiggins, the CEO of Transcend Australia, said families have told his organisation they “don’t trust” Westmead children’s hospital, and that they’re unable to access the services they need.
He said the climate around trans issues in Australia was “incredibly hostile and damaging to people who are already a highly marginalised population”.
“I think families are feeling incredibly distressed, and I would understand that they would feel that because families want their kids to be safe,” he said.
Clinical psychologist Anna said that distress was exacerbated after third parties started weaponising a report prepared by Westmead.
“They’d come to me with questions like, ‘Did you write the paper?’,” Anna said.
“There was a lot of distress, a lot of worry.”
She said senior hospital staff wrote a letter for her to give to any distressed patients.
“The letter essentially said that, ‘We are dedicated and committed to providing a gender-affirming service. We are sorry if you are distressed by the results of this paper. However, research is research, and findings have to be published’.”
The Westmead children’s hospital research focused on a sample of 79 young people who sought help at the hospital’s gender service.
In a 2021 peer-reviewed report, researchers identified complex family trauma amongst those they reviewed with “high rates of adverse childhood experiences including family conflict, parental mental illness and loss of important figures via separation”.
The researchers said a history of maltreatment was also common and they said clinicians — including them — were coming under increasing pressure to “compromise their own ethical standards … by engaging in a tick-the-box treatment process”.
They highlighted risks of going straight to gender-affirming care and made calls to implement a holistic approach to medical treatment that included a “trauma-informed model of mental health care” as a component in all gender dysphoria clinics.
The Westmead research team published another paper in February this year. It looked at the developmental pathway choices and clinical outcomes of 79 patients who presented at the hospital.
It pointed to increasing rates of what’s known as “rapid-onset gender dysphoria”, particularly amongst a small sub-set of adolescent girls.
“The absence of prior history raised questions that this particular group of adolescents were being drawn to the construct of gender dysphoria because of some evolving social process,” the report said.
Rapid-onset gender dysphoria and the theory it is caused by peer influence and social media are contested concepts. The Australian Psychological Society’s position is that empirical evidence refutes the theory.
One of the most controversial findings in Westmead’s latest research involves the concept of “desisters”, which often refers to someone who no longer identifies as trans.
But exactly how “desisting” is defined varies, including in the report, which found that gender-related distress was “resolved” or “disappeared” for 22 per cent of those who presented at the clinic.
This 22 per cent figure included some patients that did not have a formal diagnosis of gender dysphoria and were therefore not eligible for the gender-affirming medical intervention.
The finding has been seized upon by critics of gender-affirming care, as evidence that lots of young people change their minds.
Mental health expert Ian Hickie believes the data in the Westmead research does not support their conclusions, as the 22 per cent figure includes those who had come to the gender clinic but were assessed as not being eligible for puberty blockers.
“This particular way this data’s been presented is an outlier. Actually, if you go to the data that’s in the paper, it’s entirely consistent with the opposite conclusion: that it’s very rare for actual young people to completely decide to go back to the gender assigned at birth,” Professor Hickie said.
While the research did separately report on the percentage of patients formally diagnosed with gender dysphoria that changed their mind about their transition, being 9.1 per cent – Professor Hickie said highlighting the desistance rate as 22 per cent of the broader group had caused unnecessary alarm within the community.
Clinical and developmental psychologist Emerson Osterberg — who wasn’t involved with the research — said there was no one path for kids who seek help with gender issues.
“There are some kids who will go on puberty blockers and then come off it, not because they’re not trans, but because the puberty blockers didn’t feel right to them,” Mx Osterberg said.
“There are some kids who will go on to gender-affirming hormones and other kids won’t. And that’s because that’s their personal choice.
“There are some kids who will turn into adults and will access surgeries and other people won’t want that.”
The Westmead researchers’ final conclusion was that “the evidence-base pertaining to the gender-affirming medical pathway is sparce [sic] and, for the young people who may regret their choice … the risks for potential harm are significant”.
None of the research authors would speak on the record to Four Corners.
Sydney Children’s Hospitals Network said it was “required to communicate research results, whether favourable or unfavourable, in ways that permit scrutiny and contribute to public knowledge and understanding”.
The leaders of the nation’s other publicly-run gender clinics, and a pediatrician currently working on the frontline of the Westmead children’s gender clinic, have written a joint letter contesting some of the findings.
Warning: The following section includes descriptions of disordered eating and suicide.
‘We did all we could’
Noah O’Brien was another teenager desperate for help from Westmead.
He began identifying as non-binary at the start of high school, then mid last year, aged 14, he wrote his parents a letter telling them he identified as a boy.
Noah’s mum Lauren said they thought, at first, he was being influenced by a friend or someone online.
“But the longer that time went on, we just saw, no, it was definitely just him, who he was,” she said.
It was around this time that Noah started to restrict his eating quite severely.
Noah ended up at Westmead children’s hospital. He was discharged the next day with a recommendation he seek support for gender issues.
His mum went to the GP to get a referral for the hospital’s gender clinic. It was sent to the hospital last October.
But Noah’s family wasn’t told that at Westmead, he would be pushed way down the waiting list because he had begun puberty.
“Lauren rang places, went to the doctors, tried everywhere to get help, but it was just like doors were closing in her face. Nobody was responding to her call for help,” Noah’s grandmother Rose Marsh said.
When Noah was admitted to the eating disorder unit to be treated for anorexia, the gender unit’s staff decided they should try to see him.
Four Corners has learnt that a social worker from the gender service visited Noah.
An email shows how that visit unfolded:
“I met with Noah and provided him with community support information. He also mentioned that his cycles were causing distress so I wondered if menstrual management could be discussed with him?” the social worker wrote to a superior.
That discussion didn’t go ahead.
A senior staff member outside the gender clinic told the social worker she needed to “cease … involvement with Noah due to the eating disorder being the primary focus”.
Noah was effectively denied any specialist gender support by the hospital.
As the summer holidays drew to a close, Noah was anxious about returning to school. It would be the first time he’d worn a boy’s uniform.
Noah took his own life.
“I feel like he didn’t get any help or support in making that transition to become a male,” Rose said.
“We did all we could, Lauren did more than anyone ever could, but we just didn’t get any help from anywhere that could help us.”
Westmead children’s hospital’s management declined to speak to Four Corners, issuing a statement expressing their “sincere condolences to Noah’s family”.
“Due to patient privacy and confidentiality, [Sydney Children’s Hospitals Network] is unable to provide further information about his specific care.”
Evidence and ideology
Globally, access to gender-affirming care for children has been shifting rapidly.
The UK’s National Health Service will close its gender identity clinic and replace it with regional hubs after it was criticised in an independent review.
At least 20 states in the US have now banned or restricted gender-affirming care.
Puberty blockers have been wound back in European countries like Norway, Sweden and Finland, and are only to be used in clinical trials in the UK.
In Australia, there are increasing calls to limit or review gender-affirming care from people like Dr Jillian Spencer.
The psychiatrist has been stood down from clinical duties at Queensland Children’s Hospital pending an investigation into a complaint from a transgender patient.
She is contesting the allegations and has lodged a complaint with the Queensland Human Rights Commission, saying she should have a right as a doctor to object to the affirmation model for children.
Dr Spencer instead supports the “watchful waiting” model.
“That would involve engaging with them, treating mental health comorbidities, and engaging them in therapy, and family therapy if need be, optimising their school functioning and engagement, and trying to get them connected to peers and activities that help them to feel good about who they are.”
Psychologist Dianna Kenny is a member of a group that backs research into alternatives to gender-affirming care and is an ambassador for lobby group Binary Australia.
She provides “gender exploratory therapy”.
“It is not conversion therapy. It provides a safe exploratory space for children to look at themselves and to gain a greater understanding,” Dr Kenny said.
“The aim of the therapy that I practice is for the young person to know their true feelings and to express them whatever they turn out to be.”
Professor Hickie said there was no evidence that psychological therapy alone is a legitimate alternative to what is being offered through most specialist gender clinics.
“Exploratory psychological therapies, family therapies, ‘watchful waiting’ are not evidence-based. They are the sets of intrinsic beliefs of different professional groups,” he said.
People who detransition — decide to go back to the gender assigned to them at birth — are increasingly part of the ammunition against gender-affirming care.
“People as young as 18, 19, early 20s are warning their younger peers, “Don’t make the mistake that I’ve made’,” Dr Kenny said, adding there was no “good data” on the number of people who detransition.
Sam Winter said it was fair criticism of the gender-affirming healthcare model that researchers, “have not given sufficient attention to detransitioners, or also, those who desist”.
“We haven’t given enough attention to those who come out of the process with regret.”
Dr Stephen Stathis is medical director of Child and Youth Mental Health Service at Children’s Health Queensland.
He said about 80 per cent of the research on gender-affirming care has been published in the past 10 years.
“The evidence base is emerging, and it’s changing. And so, we’re constantly reviewing that evidence base and adapting our model of care to take into consideration the new evidence.”
Watch Four Corners’ full investigation tonight on ABC TV and ABC iview.