Sen. Matthew Canavan (LNP—QLD)
Sen. Pauline Hanson (ONP—QLD)
Sen. Susan McDonald (LNP—QLD)
Sen. Gerard Rennick (LNP—QLD)
Sen. Amanda Stoker (LNP—QLD)
Dear Senator Roberts,
I hope this letter finds you appropriately well.
I write with reference to your Motion No. 1114, considered by the Senate Tuesday 15 June 2021, which was not carried. The other recipients of this letter are included because they are Senators from Queensland who voted “aye.” As a resident of Queensland who is enrolled to vote, and therefore as your — and their — constituent, I am doing my civic duty and providing you with informed feedback.
As it was your motion, I assume it was drafted either by you or by someone with whom you are professionally associated. I have a few suggestions and points of issue for the next time you take legislative action on this topic. From the text of your motion —
there is an alarming trend that teenage girls, with no history of GD, have become the largest group seeking treatment.s (a)(i)
First. Some percentage of these people — statistically, an overwhelming majority of them — are not girls. The decision to classify them all as “girls” regardless is an act of misgendering which could easily have been avoided.
Second. The ratio of trans women to trans men in adulthood is approximately 1:1; however, female-assigned children who don’t conform to their assigned gender have historically been underrepresented at gender clinics, partly because people who appear to be women are taken less seriously in general, and partly because gender nonconformity is less pathologised in “girls” than in “boys” (Urquhart, 2017). It is not reasonable to describe the referral of more trans boys as “alarming” when it represents a regression toward the mean (Ashley & Baril, 2018).
Third. “Not having a recorded history of a condition until you seek treatment for it” describes the vast majority of all interactions with the medical system; one doesn’t go to the doctor for a complaint until one has that complaint. The framing used in the motion implies a very unusual understanding of human psychology.
in the United States of America, girls requesting gender reassignment surgery in 2016-17 rose 400%.s (a)(ii)
First. Again, some percentage of these people are not girls and this section of the motion misgenders them.
Second. The claim being made here is extracted from Abigail Shrier’s Irreversible Damage, which cites the American Society of Plastic Surgeons (2018) as the source. Per the fine print, the ASPS’ numbers are not their raw survey data, but instead a “projection” from it. The “projection” appears to be done in a methodologically flawed way which means that the “projections” in question do not necessarily bear, and in fact may necessarily not bear, any actual resemblance to reality (Brown, 2017).
Third. It is likely, however, that there would indeed have been a rise in treatment uptake in 2016-2017 — because it was still within the first couple of years after the US Medicare system dropped its blanket denial of public healthcare coverage for any transition therapies whatsoever (Cha, 2014).
This would extremely obviously be material to any discussion of year-on-year increases in therapeutic uptake, especially given that cost is statistically a significant barrier to gender therapies (Sineath et al., 2015), while transgender people are disproportionately impoverished, unemployed, uninsured, and denied medically necessary procedures when they are insured (James et al., 2016). Omitting this necessary context does not lend itself to a charitable interpretation of the motives of the party responsible.
in the United Kingdom, girls presenting with GD in the last 10 years rose 4000%s (a)(iii)
This statistic is presumably derived from its most common primary source, the UK High Court of Justice’s finding (Sharp et al., 2020) in Quincy Bell & Mrs A v. The Tavistock and Portman NHS Foundation Trust, known in brief as Bell v. Tavistock.
First. The parameter to which the “4,000%” figure corresponds is the rise in referrals to the National Health Service (NHS) Gender Identity Development Service, which provides counselling and, where appropriate, transition care for people who are referred with transition-related distress.
This means that the phrase “presenting with” is inaccurate — it implies that the parameter which has risen by 4,000% is the number of under-18s who think they might be trans. However, that quantity (which is unknown) is not linked 1:1 to the quantity of referrals to the Tavistock, because the Tavistock does not allow self-referral by a patient or their family (NHS Gender Identity Development Service, 2021).
What has actually risen by 4,000% is the number of under-18s who have gender-related distress that a medical professional considers sufficiently severe and credible to warrant referral to a specialist. However, this is inconvenient for the “kids being brainwashed into transition” narrative presented by this framing — because it also requires the brainwashing of a group of generally highly educated and well-informed professionals who are liable to face serious legal and reputational consequences if they are insufficiently careful.
Second. This framing implies that a dramatic difference over time is inherently cause for suspicion. This implication is baseless. The percentage of the world population who are naturally left-handed is approx. 10% (Hardyck & Petrinovich, 1977); where and when left-handed people have faced social suppression and abuse, the percentage of people who report left-handedness is less than 1% (Shimizu & Endo, 1983).
Trans people and their families have historically faced an extraordinary number of social, ideological, informational and organisational obstacles to accessing transition care even when it theoretically exists, meaning that historically they have not gotten to the point where data like referral counts would even indicate their existence. It does not create a legitimate basis for suspicion to observe that if you stop dramatically under-counting how many trans people there are, the number of trans people you count dramatically increases (Hoffman, 2016).
Australia’s Royal Children’s Hospital indicates referrals have grown from 1 every two years to 104 patients in 2014.s (a)(iv)
Many of the same points in the previous section are applicable here, with the following additions —
First. This is framed as in such a way as to suggest that this growth in referrals was rapid and unexpected. In fact, it happened over the course of eleven years (Telfer et al., 2015).
Second. Approximately 1 in every 200 adults is trans, according to US data (Flores et al., 2016), which both I and the author of the motion clearly agree is applicable here. In 2014, the reference year, the population of Greater Melbourne was c. 4,440,000 (Australian Bureau of Statistics, 2015), and likely around 18% of them were children under 15 years of age (Australian Bureau of Statistics, 2012). Extrapolating from those figures, there should be, at a very conservative estimate, c. 4,000 trans kids under 15 in Greater Melbourne in any given year.
This estimate is conservative because there are obviously kids above 15 but under 18, and because survey data suggests the rate of trans identity among current adults is socially suppressed, and the rate of trans identity among kids is actually approximately twice the reference value used above (Clark et al., 2014). What this establishes is that, compared to what it notionally should have been at minimum, the RCH Gender Service’s patient population in 2014 was worryingly small.
Sweden’s leading gender clinic has ended treatment of minors with hormonal drugs due to safety concerns, citing cancer and infertility.s (b)(i)
This references a public statement (Gauffin & Norgren, 2021) from Astrid Lindgren Children’s Hospital in Solna, Sweden, affiliated with Karolinska University Hospital and the Karolinska Institute.
The medical risks which Lindgren Hospital names in its statement include, according to the translation I consulted (“Society for Evidence-based Gender Medicine,” 2021), “cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.” It neglects to mention that many of these risks are associated with gender-affirming therapy for the same reasons and to the same degree that those risks are, themselves, gendered.
For instance, thanks to testosterone, trans men are more likely to develop heart disease than cis women — the same is true among cis men, for the same reason (Endocrine Society, 2015). Thanks to estrogen and progesterone, trans women are more likely to develop breast cancer and thrombosis than cis men — the same is true among cis women, for the same reason (Cavalieri et al., 2006; Filardo, 2018). The risk of breast cancer among trans women in general is lower than among cis women in general (de Blok et al., 2019), and the risk of thrombosis is higher or lower depending on the specific formulation used (Goodman, 2021).
The extraordinarily vague way in which the risks are stated also lends itself to misleading conclusions about how they come about. If someone took puberty-suppressing medications for a very long time, they would likely develop osteoporosis — in much the same way that if I were to swallow the rest of this month’s refill of ADHD medication in one go, I would probably die. There is no meaningful risk of osteoporosis arising from normal use of puberty blockers in the context of gender-affirming care (Heger et al., 1999).
Moreover, the reason puberty-suppressing medication can cause osteoporosis if taken for extraordinarily long periods is because it blocks sex hormones, and low levels of sex hormones are the most important factor in the development of osteoporosis (Sinnesael et al., 2013) — meaning that actually administering cross-sex hormones relieves the risk entirely.
Finally, an argument to fertility seems deeply unsuitable here. The same argument can be made about chemotherapy for cancer (Cancer Council Victoria, 2021), anti-seizure drugs for epilepsy (Sukumaran, Sarma & Thomas, 2010), and even common off-the-shelf medications like ibuprofen (Leverrier-Penna et al., 2018; Kristensen et al., 2018). It is understood that the benefit these medications provide to quality of life, and indeed often continuation of life, is sufficient to warrant their use regardless. The same is unambiguously true of gender-affirming treatment (Cornell University, 2021); therefore one is obliged ethically to take the same position.
As a side note, the Institute’s public statement effective 1 April notes the Bell v. Tavistock decision cited above as an essential component of its own decision — but fails to note that the Court reversed the relevant part of its decision in the month prior to the Institute’s policy change taking effect (Parsons, 2021). This does not inspire confidence that the most current information is being used either by the Institute or by Australian politicians relying on its conclusions.
suicide mortality rate for transgendered people is 20 times higher than comparable peerss (b)(ii)
First. “Transgendered” has now been out-of-date and offensive terminology for at least a decade (Herman, 2011), and is explicitly excluded by relevant style guides (Lopez, 2015). That raises questions about how this editorial decision was made — among politicians, an occupational group known specifically for having to perform sensitivity to public opinion, it would be extraordinary if it were accidental.
Second. This is a relatively common canard based on a widely circulated study by Dhejne et al. (2011). As when the Australian Christian Lobby’s Lyle Shelton tried this approach (Kõlves, 2016), the implied or explicit argument is invariably that transgender people’s increased suicidality is caused by transition-related medical interventions themselves.
However, this is unambiguously not in fact the case. The factors in suicidality among trans people have been identified, and include discrimination, hostility, post-traumatic stress, prejudice, shame, social anxiety, and stigma (Haas et al., 2011; Marshall et al., 2015; Pandya, 2015; Skerrett et al., 2015; Williams & Dhejne, 2015).
To suggest that suicidality in trans people indicates we should further restrict their access to treatment known to relieve it is, optimistically, a misunderstanding that beggars belief. Out of a desire not to be hurtful, I have opted not to detail the pessimistic view.
the ‘wait and see’ method as the first choices (c)(i)
“Wait and see” is already the first choice. Under the current international clinical standard, published by the Endocrine Society in 2017, unless there are exceptionally medically compelling reasons to begin earlier, it is not part of normal practice to initiate hormone treatment before 16 years of age (Hembree et al., 2017). Prolonging puberty suppression treatment for much longer than that would lend itself to the side effects which the motion’s author professes to wish to avoid. Failing to provide puberty suppression treatment would lead to a currently permanent and irreversible decline in the efficacy of later transition, which could not in fact be ethically justified.
Given that puberty suppression has no effects other than shifting the time at which the normal puberty process begins and proceeds, the suggestion that it represents a departure from “wait and see” is not a coherent one.
evidence shows between 70—90% of young people’s dysphoria resolves itself by pubertys (c)(i)
This is an often-mentioned, rarely-sourced factoid. It is rarely sourced because it is bunk.
It is based on a cluster of studies, primarily Steensma et al. (2011) but also a number of others that are similarly constructed (Winters, 2014), which between them appear to boast an impressive array of methodological flaws (Temple Newhook et al., 2018), including:
- assuming that any and all children who could not be located for follow-up — nearly half of the study population — must have desisted, a level of assumptive confidence seen in virtually no other research whatsoever (Ford, 2017);
- not bothering to distinguish between children who are comfortable in their assigned gender but are perceived as gender-nonconforming, and children who are actually consistently, persistently, and insistently trans (Tannehill, 2017);
- treating subjects who didn’t transition by follow-up as desisters even if they’d never presented as trans in the first place (Winters, 2016).
An argument which relies on studies with these flaws as a source of supporting information is not an argument that is well-sourced, well-supported, or well-informed.
a comprehensive therapeutic pathway since a large percentage of these children have pre-existing mental health issues, and not a medical pathways (c)(ii)
First. The pre-existing mental health issues in question are most commonly major depressive disorder and similar conditions (Meybodi et al., 2014); i.e., they are not, as this framing implies, issues which are regarded as impairing the capacity to give informed consent.
Second. The pre-existing mental health issues in question are reliably and consistently relieved by transition (Cole et al., 1997). As previously stated, framing them as a reason to bar access to transition care does not reflect reality.
Third. A mental health therapeutic pathway which was non-medical would necessarily also exclude psychiatric care, which is a medical specialty (Gaebel et al., 2010). There is no evidence to suggest that any intervention other than transition reliably relieves gender dysphoria, but the suggestion that such a hypothetical intervention should not include “a medical pathway” does not, even in that hypothetical universe, reflect an intention to ensure that the distress of trans people is relieved.
experimental and unproven medical treatments of irreversible puberty blockers and sex hormone treatments, and […] irreversible transgender surgerys (d)(i) et seq.
First. Given that sex hormones are an extremely basic part of medicine and are widely and trivially known not to be experimental, this is presumably a revival of the claim that puberty blockers are experimental, which is false (Giordano & Holm, 2020). They are used “off-label,” that is, for a purpose different for the purpose for which they are licensed. This practice is ubiquitous in all paediatric healthcare because many medications which are unequivocally necessary for juvenile patients have only been tested on adults and are therefore only licensed for use in adults (Cuzzolin et al., 2003; Magalhães et al., 2015; Balan et al., 2018). Off-label prescribing in paediatrics is endorsed by the relevant peak bodies for this precise reason (Sharma et al., 2016).
Second. It is factually untrue that puberty blockers are irreversible. They are fully reversible (Murchison et al., 2016). Hormone replacement therapy and sex reassignment surgery have aspects that are irreversible — because of course they do, that’s the point. The idea that the irreversibility of gender-affirming pharmacotherapy and and surgery should be a bar to its use is fundamentally dependent on the assumption that there are no trans kids, that later in life they will invariably “snap back.” There is no evidence to suggest that.
Third. It is factually untrue that either puberty suppression or gender-affirming hormones are unproven. Both puberty blockers (Alegria, 2016; Mahfouda et al., 2017; Rafferty et al., 2018; etc., etc.) and gender-affirming hormones (Newfield et al., 2006; Johansson et al., 2009; Byne et al., 2012; etc., etc.) have a long prescription history and body of literature demonstrating that they are thoroughly safe and effective. To assert otherwise is either to be ignorant of the professional consensus, or to knowingly contradict it in order to advance political ends. Out of politeness, I will refrain from asserting which.
I, and most likely the vast majority of your other constituents, expect that when our Senators vote on real-world issues, they will inform their votes with real-world facts, which they have more than sufficient resources to do. Your choice to move this motion and your co-addressees’ choice to support it presents two alternatives:
- You and/or they were not acquainted with the facts (disappointing);
- You and/or they were acquainted with the facts but chose to ignore them for the sake of political advancement and power (disgusting).
It would be most gratifying to believe that you will do better in future.
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