Four Corners' Failure
In its treatment of gender clinics, the flagship investigative program of the Australian Broadcasting Corporation failed to present crucial evidence.
Public broadcaster the ABC is often billed as “Australia’s most trusted source of news and current affairs.” But the ABC, like other media outlets with progressive political cultures, has a problem. How do journalists who identify as being on the right side of history—journalists proud to be known as transgender allies—execute a course correction under pressure from an emerging medical scandal?
For a decade, progressive media has been reading aloud the story of the brave trans child. These are the trans kids who have suddenly proliferated in a more welcoming, medically clued-up society, but who were always with us, all the way back to pre-history, only hidden by ignorance and bigotry. Or so the story goes. And now they emerge as the authentic trans kids they always were by subjecting their bodies to life-altering hormonal and even surgical transformation.
Fortunately, this is a rare kind of medicalisation that is politically and culturally progressive; any skepticism, therefore, is right-wing. Yet we are told gender clinics are still undergoing a liberating process of depathologisation, so that the child’s inner trans identity will no longer be tainted by the word “disorder”, and medical treatment may continue as an expression of lived experience, not a degrading diagnosis. Some trans kids will medicalise, and some won’t—for trans kids are experts in themselves—and it just so happens that when hormones and surgery are indicated, they prevent an otherwise almost inevitable suicide. Although society is more open to gender-diverse identities, we must remember that transphobia is built into its very structure, and this makes it seem that trans kids suffer from all kinds of individual conditions such as depression, anxiety, autism, eating disorders or borderline personality disorder. In truth, the trans brand that is everywhere promoted belongs to one of the most marginalised minorities on the planet, and society is to blame.
The ABC’s problem is not really the incoherence of the trans kids story, which can be compelling on an emotional level. No, the problem is a seemingly boring international trend begun in cold Nordic countries less than five years ago. Some clinicians had been worrying away at the poor outcomes of medicalised gender change offered to ever younger patients; this is a relatively new enterprise. Health agencies in Finland and Sweden commissioned “systematic reviews” of the evidence base; England did the same.
Where TV programs celebrate a handful of engaging trans kids and their ever-confident doctors, a well-devised systematic review pulls together all the relevant studies for these hormonal treatments of minors with gender dysphoria. It’s about impersonal evidence, not identity validation; the concern is safe and effective treatment, not cosplaying a civil rights crusade. Systematic review uses an up-front, reproducible method to analyse the strengths and weaknesses of the scientific literature and make findings about the quality of the evidence base. Which turns out to be very weak and uncertain, meaning we can’t have much confidence at all in the benefits claimed for youth gender medicine. What remains are the risks, with minors supposedly able to give informed consent to possible outcomes including lifelong medicalisation, infertility and sexual dysfunction as adults, low bone density and early osteoporosis, vaginal atrophy, embolism, and heart disease—plus the as-yet-unknown hazards.
And so, with patient policy work and little sign of tribal politics, health officials and researchers in Finland, Sweden and England have independently reached a new consensus. Medicalised gender change for minors is experimental, so it should no longer be easily available as a routine response to what looks like gender distress. And first-line treatment should re-emphasise psychological methods within a holistic mental health approach. Gender transition is no panacea.
This constitutes a serious challenge to clinicians who have been offering puberty blocker drugs, synthetic opposite-sex hormones and double mastectomies as lifesaving “affirmation” of trans kids. How will clinicians and trans-ally journalists respond?
In the United States, home to the politicised “gender-affirming” treatment approach, the helpfully parochial response has been to ignore or misrepresent these inconvenient international developments, while arguing that gender medicine is all-American “settled science” endorsed by all the big-name medical associations. This appeal to trust in self-confident experts—the clinicians heroically engaged in what may be a medical scandal—has been deprecated as “eminence-based medicine”. It’s often paired with what might be called suicide-based risk recalibration, in which exaggerated fear of self-harm is induced to make no treatment seem riskier than its possible side effects. All this is packaged as a political melodrama in which normal caution about medicalising vulnerable children is headlined in mass media as an Anti-trans Culture War Fought over the Bodies of Trans Kids Who Just Want to Exist.
And this is the culture war imported by the ABC’s flagship TV investigation program Four Corners last week. Its counterpart programs in Sweden (Mission Investigate on the public broadcaster SVT) and Britain (BBC Newsnight) did actually scrutinise gender-affirming clinics and exposed their dangers, thereby contributing to the adoption of more cautious treatment policy. Even the painfully progressive New York Times has interspersed its politicised misreporting of gender medicine with occasional more balanced fare such as the 2022 article headlined They Paused Puberty, but Is There a Cost?
Monday on Four Corners: pic.twitter.com/KaW66eV9Ve
— Four Corners (@4corners) July 5, 2023
The Four Corners program is in some ways an improvement, but only relative to the ABC’s woeful past coverage—or non-coverage. Knowing that any less-than-affirming coverage would be seen as a betrayal, the ABC issued a 900-word editorial which can be read as a preemptive apology for doing journalism.
In the July 11 Four Corners episode “Blocked: The Battle over Youth Gender Care”, ABC viewers were at last allowed a glimpse of expert disagreement about gender medicine for minors. They got to see a real live (although not-very-regretful) detransitioner who had moved on from testosterone treatment. And the audience could infer from the journalist’s questions that it’s not absurd to suspect social contagion as a cause of the explosion in trans and non-binary avatars among teenage girls. In its ample 55 minutes on air, the program managed a fleeting reference to the evidence thing. We were told that Nordic countries had “wound back” puberty blockers and that in England those drugs would be restricted to clinical trials because the National Health Service (NHS) had determined “there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment.”
Here was the crucial moment where obvious questions would plug Australian viewers into the international picture. Clinical trials? Does that mean puberty blockers are experimental? You mean the same blockers given as routine treatment by gender clinics in Australian children’s hospitals? Do our clinics have better evidence than England’s NHS? Or is it the case that the Nordic countries and England are opting for caution because the evidence base for medicalised gender change with minors is the same internationally? Is there some agreed method for testing the strength of the evidence—a method that can withstand the polarised debate about gender clinics?
But those questions went unasked, and the program never seriously interrogated the weak scientific foundation for gender clinics. From its brief mention of the NHS clinical trials, Four Corners threw to an Australian professor of psychiatry, Ian Hickie, who presented the scandal at the NHS-commissioned Tavistock gender clinic as a one-off instance of “bad management” of complex patients, where the “approaches were [not] intrinsically wrong.” This would surprise anyone familiar with the 2022 interim report of paediatrician Dr Hilary Cass, who heads England’s independent review of youth gender care.
She certainly does identify intrinsic problems with the dogmatic gender-affirming treatment approach—for example, “diagnostic overshadowing”. Dr Cass explains that “many of the children and young people presenting [at the Tavistock clinic] 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.”
"From the point of entry to [the Tavistock clinic] there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision."
Dr Cass contrasts the gender-affirming approach with a more cautious exploratory approach that takes account of what we know about child and adolescent development. It’s clear which approach Dr Cass regards as safer, however tactful her language.
And hormone suppression—with its promise of blocking “the wrong puberty” for trans-identifying children—is integral to the approach of gender-affirming clinics, not just the Tavistock. And, again, Dr Cass in her report raises profound concerns which transcend merely managerial issues—
The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminates in progression to feminising/ masculinising hormones by impeding the usual process of sexual orientation and gender identity development.
Four Corners had an opportunity to pursue the serious uncertainties of blockers when it turned the camera on Dr Ken Pang, head of research for Australia’s most influential gender clinic at the Royal Children’s Hospital (RCH) in Melbourne. But he was not asked why the RCH clinic had launched a study of the unknown effects of puberty blockers on the brain only last year, having offered these drugs as a routine intervention for well over a decade. This is a medication used off-label to suppress natural sex hormones and normally timed puberty, but viewers were told nothing of growing fears that this intervention may affect critical windows for development of the adolescent brain.
The unconvincing claim that puberty suppression is reversible was not tested. Cross-sex hormones, which are acknowledged as bringing irreversible changes, were airily said to be “often the next stage” after blockers. In fact, according to all available data, the vast majority who begin taking blockers go on to take cross-sex hormones. The idea that blockers allow a child time to think before committing to lifelong dependence on synthetic hormones has been memory holed. Unmentioned were the likely sterilisation and future sexual dysfunction of children started early on blockers and proceeding to cross-sex hormones. Also unexamined were the implications for informed consent of a one-way medical pathway embarked on at age 10-12.
Instead of checking Australian gender-affirming clinics against the evidence base, Four Corners presented an irresponsible morality tale. This suggested that being unable to access gender-affirming treatment at a Sydney children’s hospital, known as Westmead, caused the suicide of a 14-year-old female who identified as a boy. By implication, gender-affirming care is lifesaving and no other evidence is needed. Westmead was also a target because its researchers had published papers critical of gender-affirming medicalisation and insisting on proper exploration of factors—such as family trauma, sexual abuse, depression or autism—that might underlie what is presented as gender distress. This is heresy; most of Australia’s children’s hospitals follow the gender-affirming creed.
Right now in Australia, unsurprisingly given the European shift to caution, there are early signs of political and professional pressure for a national inquiry into youth gender medicine. But Four Corners and its morality tale have inspired a potentially misdirected review in the state of New South Wales (NSW). On the day of the broadcast, Health Minister Ryan Park declared on ABC radio that, “We’re not enabling people to access this level of healthcare as frequently as they need it.”
He said a Sydney health consulting firm, the Sax Institute, would review “research and evidence across the board in relation to this treatment and care, and health services in this space, to make sure the [gender clinic] hubs that we have are providing the best care, evidence-based care that is up to date.”
That might be easy money for Sax. It brokered the 2019 international evidence check ordered by the NSW Health Department after I reported health professionals’ concerns about the safety of gender clinics in The Australian newspaper. I kept asking the department how the evidence check was going, until it went quiet. Last year, the NSW government launched its $12m LGBTIQ+ Health Strategy 2022–2027. It is a cartoonish activist charter for statewide expansion of the gender-affirming model.
The concerns of the Westmead researchers have been ignored, so has the international scientific literature on gender dysphoria. There is no reference in the new strategy to the 2020 report of the Sax evidence check, which had predictably found that the overall rating of the evidence for medicalised gender change with minors was “low quality”. The Sax report was briefly a public document, then buried. Last year, in defence of a new government-run gender clinic, NSW health officials falsely claimed that the Sax report had “found strong evidence for a gender-affirming approach to health care.”
Might the new health minister show some curiosity, even scepticism, about the advice from his bureaucrats? It’s hard to evade the state of the evidence forever.
Consider the tragic case of the 14-year-old suicide at the heart of the Four Corners program. The child had been diagnosed with anorexia and gender dysphoria at Westmead hospital. The key clinical judgment appeared to be that the eating disorder should be “the primary focus” of treatment. But Four Corners implies that anorexia was a symptom of dysphoria and notes the lack of “gender-focused care.” Had the gender focus prevailed, it might have been a case of the diagnostic overshadowing documented by Dr Cass. We cannot know either way.
But someone at the ABC must be familiar with the standard mental health advice not to oversimplify suicide, nor to harp on an alarming risk supposedly affecting a particular group such as trans-identifying youth. The adolescents in today’s gender clinics often suffer from pre-existing conditions such as depression, anxiety or autism which themselves involve an elevated suicide risk. There is no good evidence to support the assumption that gender dysphoria itself carries a uniquely high risk of suicide, nor that trans-identifying youth will attempt to end their lives if they are not given swift access to the medical interventions promoted by social media influencers.
The Wall Street Journal recently hosted a lively exchange of letters on just this topic. Dr Stephen R Hammes, president of the Endocrine Society, whose members ought to know something about hormonal treatments, was championing the gender-affirming way. He claimed that more than 2,000 studies since 1975 showed this treatment approach to improve well-being and reduce the risk of suicide. He said nothing of the quality of these studies, nor their relevance to today’s teenage females with atypical dysphoria given liberal access to gender-affirming medication.
The Hammes letter provoked a stinging rebuke from a group of 21 clinicians and researchers from nine countries involved in care of the fast-growing numbers of teenagers presenting with gender distress. The first signatory was Finland’s leading expert on youth gender dysphoria, the adolescent psychiatrist Professor Riittakerttu Kaltiala, whose internationally significant work was essential to her country’s initiation of the European shift to caution.
The group letter to the WSJ says: “Dr Hammes’s claim that gender transition reduces suicides is contradicted by every systematic review [of the evidence base], including the review published by the Endocrine Society, which states, ‘We could not draw any conclusions about death by suicide.’
“There is no reliable evidence to suggest that hormonal transition is an effective suicide-prevention measure.”
It was convenient for Four Corners to avoid discussing such systematic reviews. If it had properly reported the evidence there would be no suicide morality tale to distract from the nature and risks of gender medicine.
All in all, the program simply did not give parents enough of the information necessary “to protect their children and make good decisions” for them, according to the Australian child and adolescent psychiatrist Dr Jillian Spencer, who was interviewed for the Four Corners episode.
She got a better hearing on Sydney’s commercial radio 2GB and expressed her dismay at the stoking of suicide fears to promote the gender-affirming medical model.
Ben Fordham
“To my knowledge, never before in mental health has [an exaggerated] death rate been used to promote interventions for children that are so poorly evidence based and have such a high risk of harm,” she said.
