A window opens on how doctors treat troubled transgender teens

In a landmark case about gender dysphoria, a Family Court judge in Sydney ruled last week that a 16-year-old boy should be allowed to transition to a girl over the objections of his mother.

The 51-page judgement written by Justice Garry Watts gives us a unique opportunity to peer into the legal and medical background of a distressed teenager who believes that he his anguish will be relieved by transition to the opposite sex.  

The parents of “Imogen”, the pseudonym used by the Court for a boy named Thomas, are divorced and at loggerheads over the transition. His mother opposes it; his father, with whom he lives, supports him. That’s why the case ended up in the Family Court.

Imogen apparently has felt as though he was a girl from the age of 6 or 7. With his father’s encouragement, he had already begun puberty suppression (stage 1 treatment). He wanted to begin oestrogen treatment under a doctor’s supervision at a Sydney gender clinic – this would help him develop feminine characteristics, including growing breasts (stage 2 treatment). This was blocked by legal action by his mother.

Now he can go ahead. Imogen and the father were elated. "We got the result last night and we had a bit of a cry," Imogen's father told the Sydney Morning Herald.

The judgement, written by Justice Garry Watts, made one positive contribution to the debate over transgender treatment, albeit technical. It clarified the position of Australian law for minors want to transition to another gender.

It certainly needed to be clarified. The judge rebuked Royal Children’s Hospital Melbourne, the authors of The Australian Standards of Care and Treatment Guidelines for transgender children, for getting it seriously wrong.

The Standards tell patients, parents and doctors that “current law allows the adolescent’s clinicians to determine their capacity to provide informed consent for treatment”.

But this is false, as Justice Watts points out. The Standards “incorrectly state the current law in relation to the need for the consent of parents/guardians to stage 2 treatment”, he notes quietly.

In fact, the position of the law is that “if there is a dispute about consent or treatment, a doctor should not administer stage 1, 2 or 3 treatment without court authorisation”. The information given by Royal Children’s Hospital Melbourne was misleading, allowing doctors to usurp the role of judges. "Current law allows the adolescent’s clinicians to determine their capacity to provide informed consent for treatment," say the Standards.

What issue could be more important than consent in deciding whether to give a teenager treatment which will change his or her life for ever? Yet these highly praised Standards have been giving children, parents and doctors the wrong information about the law. It doesn’t inspire confidence about how they handle clinical matters.

Justice Watts declared that a correct interpretation of the law takes into account the objections of a parent. If neither of them object, a competent child who wants to transition is free to commence treatment without intervention from the courts. If one of the parents raises objections about consent, diagnosis or treatment the family court needs to step in.

In this case, Imogen’s mother alleged that he was not “Gillick competent”, the standard used to determine whether a child can make legally-binding decisions. She said that Imogen was unable to fully understand treatment with cross-sex hormones and had a misplaced confidence in the positive effects of transitioning. She suggested psychotherapy rather than medication for Imogen’s gender dysphoria.

But Justice Watts declared that Imogen was competent to understand the gravity of the issues involved and could commence treatment.

However, I wonder if any sane parent would agree with him after being told Imogen’s life story. The section “relevant background” in his judgement makes very troubling reading.

Imogen’s parents were both born overseas. They began cohabiting in the mid-90s, moved to Australia in 1996, and married in 2003. They had two children, Imogen, who is now 16, and Olivia, who is 12.

In recent times, at least, the marriage was characterised by bitter disputes and violence. The spouses separated in 2017 and both subsequently remarried. The father’s new partner, Ms R, “was doing research on Gender minorities and their access to medical treatment” -- which may have influenced Imogen’s decision to transition.

Both children have been desperately unhappy for several years.

In 2017, when she was about nine, Olivia was diagnosed with complex trauma by a psychiatrist and began to take anti-anxiety medications. About the same time she began to display symptoms of anxiety like nail biting, hiding in boxes, behaving like a cat, being petrified by loud noises, having severe phobias including a phobia of grass, having daily psychosomatic symptoms including an upset tummy and hot flushes, running away from home, and regressing to baby behaviour such as sucking dummies.

By 2018, Imogen was playing video games excessively, was refusing to go to school, and was “lonely and depressed”. A psychiatrist prescribed Zoloft for a “major depressive illness”. Imogen began to be aggressive and defiant towards her mother.

In October 2018 Olivia and Imogen went on a week-long holiday with their father and Ms R. Immediately afterwards, Imogen told her mother that she wanted to become a girl. Her father started using female pronouns in conversations with her.

In early 2019 doctors at an unnamed gender clinic diagnosed Imogen with gender dysphoria. In April she began Stage 1 treatment. Imogen also had her sperm frozen and started purchasing unprescribed feminising hormones from overseas over the internet. Her father helped her to use it.

Whichever way you look at it, this is a seriously dysfunctional family and Imogen is a very troubled teenager.

The court heard testimony from two psychiatrists, one supporting hormonal treatment as a way of coping with gender dysphoria, and the other proposing psychotherapy. Her own psychiatrist agreed that she has suffered or currently suffers from social anxiety disorder with panic attacks, a communication disorder bordering on autism spectrum disorder, a probable internet gaming disorder, parent-child relational problem, sibling relational problem, exposure to family dysfunction and domestic violence, and disruption of family by separation or divorce.

Nonetheless, Justice Watts concluded that Imogen is still competent to choose to take gender-affirming hormones. “Imogen understands that the proposed treatment is not a magic bullet for all her psychological and social difficulties,” he writes. “Her hope is that treatment will reduce her Gender Dysphoria to manageable levels.”

Will it? How could anyone believe that the problems of a child with such a complicated psychiatric history will disappear if he is chemically castrated?

Very seldom does the public have an opportunity to see exactly what goes on behind the scenes of teenage gender transition. Do other kids being treated for gender dysphoria share Imogen’s appalling life story?


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