What Four Corners got wrong in their investigation into youth gender care
'Blocked' did some important investigation, but failed to stick the landing due to a misplaced and harmful focus on "objectivity".
Last night, Four Corners ran an episode called Blocked: The battle over youth gender care, an investigation into gender affirming care. It was met with mixed reactions.
Blocked, which was led by veteran journalist Patricia Karvelas, attempted to offer a sympathetic perspective on transgender lives, but also while attempting to fit it into the increasingly hostile media landscape. A tough order, and one that the ABC has routinely failed to meet in the past. This episodes comes only a week after a widely criticised episode of Media Watch dealing with transgender issues.
The program focuses on the problems with the medical community is having in Australia with the increased demand for gender affirming care. Karvelas interviews a range of transgender individuals, mainly children, and their parents, alongside a variety of medical experts, in typical cisgender journalist fashion.
However, in the presumed pursuit of “balance”, she also interviews some doctors who are against the accepted model of gender affirming care, as well as an anti-trans detransitioner. This meant that Karvelas was simultaneously interviewing a mother of a trans child who had taken his own life as a result of being given insufficient healthcare, and a former psychologist who had been stood down for advocating against healthcare for trans kids.
The episode spends a lot of time talking about Westmead Hospital in Sydney, which has been accused of producing misleading research around gender affirming care. As a result, the NSW Health Minister has told radio this morning that there is a “need to improve”.
While the episode touches on a range of medications that trans people use, the primary focus of the report was puberty blockers, hence the episode’s title. The show heavily implies that blockers are a new and experimental medication developed specifically for trans kids. This is not true. Blockers were first approved in the US by the FDA in 1993, and were first developed for cis kids undergoing “precocious” puberty. At no point had their supposed dangers attracted media attention until three decades later, when their use on trans kids was becoming more widely known. Karvelas never mentions this, despite it all being easy to research on Wikipedia, and if she did it would have given her report an entirely different look.
However, the most arrant mistake she made was the inclusion of the anti-trans lobbyists in the episode. She hypocritically alludes to the corruption, bigotry and malpractice in gender affirming care when referring to a peer-reviewed paper advocating for conversion therapy, and yet still interviewed two primarily anti-trans doctors.
Karvelas disclosed the connections of Dr Dianna Kenny to the organisation Binary Australia, but refused to state the far-right/ extremist activities of this hate group. Binary’s spokesperson Kirralie Smith, for example, campaigned against same-sex marriage and Islam in Australia, and faces two AVOs in New South Wales for harassment. Jillian Spencer appeared on the show repeating anti-trans dogwhistles and advocating for “watchful waiting”, a practice that is often combined with conversion therapy, which is banned in Queensland. Neither of these people could be described as experts in this field, and seem to have only been approached because of their established anti-trans bias.
The result is that Karvelas, whilst well-intentioned, delivered a report that felt contradictory and confused. The sad and insulting irony of delivering a story which put the fatal mismanagement of the gender affirming healthcare system into stark view, but also interviewing people effectively advocating for further deaths in this system, could not escape me. The deadnaming of this child in the report was also deeply insensitive, as tragedies of the trans community are often mocked, underplayed, or used to serve as cisgender trauma porn.
It seemed to me that Karvelas intended to make a report showcasing abuse of power in gender affirming care, and that would be an incredible piece of investigative journalism perfect for Four Corners – but she failed to deliver due to these mistakes.
Instead, her piece and her decision to give those same abusers of power airtime, made that power imbalance worse for transgender kids.
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Natalie Feliks is a writer and activist originally from Adelaide, now living in Melbourne. She's written for the likes of Junkee, Crikey, and Overland, and spends her time listening to pop music and eating chocolate.
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It's completely untrue to say that rigorous studies aren't possible in circumstances where Randomized Controlled Trials would be impractical and / or unethical. High quality observational studies such as cohort studies and case-control studies with adequate follow-up periods and valid measures of the variables of interest can be a valuable source of data. Natural experiments or quasi-experiments where an intervention group and a control group with reasonably similar demographic and clinical characteristics were effectively created by decisions or circumstances beyond the researchers' control - such as government policy decisions that applied to some people but not others, or natural events that affected some people but not others - can also be very useful.
Gender health care for children and adolescents is probably the most politically polarized and the most emotionally charged area of health care today - even more so than abortion and voluntary assisted dying. It seems to me that our societies could be doing so much more to normalize a wider range of gender expression. People who are nominally on the progressive side of the gender health care issue pay lip service to the idea that there are many ways of being a boy or a man, and many ways of being a girl or a woman, but it appears as though gender transition is sometimes framed as the default response to children and adolescents who question their gender. In reality it is just one option among many others, such as providing psychosocial support and psychological therapeutic support to explore what gender can mean, to foster a healthy sense of self, to address bullying and social exclusion, to build belonging and a sense of purpose, to improve communication and relationships with parents, siblings, and peers, to treat trauma and stressor-related disorders, neurodevelopmental disorders, anxiety disorders, mood disorders. We should also be using popular culture, the mainstream media, and the education system to increase societal acceptance of unconventional forms of gender expression.
I think that psychiatrists, paediatricians, and endocrinologists should have the option of prescribing puberty blockers and cross-sex hormones to children and adolescents when they think it is clinically indicated. The clinical practice guidelines probably need to be tightened up so that psychosocial and psychological supports are prioritized, and medical transition is only used when those other supports aren't working to alleviate the person's distress. That would require increased federal government spending on psychosocial and psychological supports, which are currently under-funded not only in cases of gender-questioning children and adolescents but across the health care and disability systems in general. It seems to me that some areas of health care are overly medicalized because it is perceived as cheaper and simpler to prescribe medications than to provide psychosocial and psychological support, to guarantee people good quality housing, to guarantee people good quality education from early childhood to university, to guarantee people paid work, and to guarantee income support that is above the Henderson Report poverty line (currently about $90 per day for a single person) to people who need it.
The medical ethics of providing a medical gender transition to a child or an adolescent are complex. A minor by definition does not have the autonomy and the decision-making capacity of an adult. The extent to which a child can give genuine informed consent to far-reaching medical interventions that don't have a strong evidence base and that have significant side effects is questionable. It probably should be an option that's available in some cases but presenting it as the standard response to a child or adolescent who is questioning their gender makes no sense and is not a progressive perspective on this issue.
I think it's very disturbing that scientific research in this area of health care doesn't have the freedom to question the merits of medical gender transition as a therapeutic response to gender-related distress. Scientific research is supposed to be about the pursuit of truth. It isn't supposed to reinforce or signal a set of political commitments. Practitioners who don't like the studies that question medical transition as a treatment and that favour psychosocial and psychological interventions should critique the research methodology on scientific grounds. They should do their own, more rigorous studies. They shouldn't try to stifle other researchers' work. They shouldn't equate questioning medical transition as an intervention with being transphobic or bigoted.
Last year Four Corners on the ABC in Australia did a documentary about youth gender health care. The documentary mentioned some scientific studies that were done with patients of a gender health clinic at Westmead Hospital in Sydney. The studies questioned the efficacy, tolerability, and safety of hormonal treatments for gender-questioning children and adolescents and suggested that psychosocial and psychological supports need to be given more emphasis than they currently get. There were some mental health clinicians at the gender clinic who argued that the executives of Westmead Hospital should have suppressed or disavowed the studies because they amounted to the erasure of transgender people. I found that very disturbing. Mental health clinicians such as psychologists, social workers, clinical nurses, occupational therapists and so on are from scientific disciplines, so they are supposed to understand how scientific inquiry works. Instead of making detailed methodological arguments about the studies and proposing additional studies with better methodologies they saw it as a political issue that called for the political act of condemning a group of researchers and portraying those researchers as transphobic. The experiences of gender-questioning children and adolescents are often a lot more complex than, "Here is a civil rights category of oppressed people who need to be empowered." There are challenges relating to physical and cognitive and emotional development, sexuality, body image, sense of self, emerging independence, changing relationships with parents and siblings and peers, and sometimes there are experiences of autism, ADHD, anxiety disorders, mood disorders, eating disorders, substance use disorders. There are quite a lot of reasons why a child or adolescent might be questioning their gender. It seems unwise to assume that a medical gender transition is the solution in these circumstances. Keep that option available when clinically indicated but don’t regard that option as the default. Properly resource non-medical responses to distress. Engage with the person in all of their complexity. Maybe the social influence / social contagion aspect of gender questioning in children and adolescents could be related to the pressure that young people are under today to have a brand and a following. In the pre-social media age there was peer pressure but not with the same level of ubiquitous and constant presence created by social media.