Precis

How to care for the increasing number of young people struggling with their gender is the subject of heated global debate.

At the heart of that debate is whether medical interventions, including puberty blockers and cross-sex hormones, should be administered to young people.

The fight is now boiling over in Australia among frontline clinicians and is playing out dramatically at Westmead children's hospital in Sydney.

This week on Four Corners, RN Breakfast presenter Patricia Karvelas breaks open the feud over transgender youth healthcare.

Patricia and the team deftly navigate polarised arguments and interrogate scientific research in a quest for answers about what the best model of care is.

Along the way they meet young people who are transitioning and speak to parents desperate to get help for their children who are in distress, as well as clinicians from both sides of the debate who are daring to speak out.

Four Corners sensitively tackles what has become akin to a culture war.

4 Corners animated logo

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00:00

Program intro teaser

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00:12

PATRICIA KARVELAS: There's a bitter war underway over the control of young people's bodies.

00:17

SAPPHIRE: The body that I'm in, I don't want to be in this anymore.

00:23

ALISON: She was born with a boy's body, and she has a girl's heart and mind.

00:28

PATRICIA KARVELAS: Transgender kids are at the centre of a polarizing debate over medical intervention to help deal with their distress. The recognised  treatment in Australia includes drugs to pause puberty.

00:35

DR TRAM NGUYEN, Lead psychiatrist, Royal Children's Hospital Gender Service: It's not one session and you get hormones, that's a total misconception about what we do.

00:48

PATRICIA KARVELAS: Opponents warn medication is dangerous.
"Do you think there's ever a case for an adolescent to transition medically?"

00:55

DR JILLIAN SPENCER, Child and adolescent psychiatrist:  My personal opinion is that it would be good to disallow the prescription of puberty blockers to children with gender dysphoria

01:05

PATRICIA KARVELAS: Now the conflict is being played out in hospitals, and at the centre is Westmead Children's in Sydney.

01:10

RENEE WILLCOCKS: We called Westmead Children's Hospital, as empathetic as they were to our situation, they couldn't help us.

01:19

PATRICIA KARVELAS: The waiting lists for gender care are growing.

01:25

ANNA, Clinical psychologist: I'd have families emailing, calling, and saying, "My child's so distressed, we need to do something."

01:28

PATRICIA KARVELAS: And it's the kids at risk.

01:35

LAUREN O'BRIEN: I was bargaining with God. I wanted him to come back. I was praying.

01:39

Crowd chant: "Trans lives matter."

01:44

PATRICIA KARVELAS: All this against a wave of anti-trans sentiment sweeping the globe.

01:46

DONALD TRUMP: The left-wing gender insanity being pushed on our children is an act of child abuse. 

01:51

KELLIE-JAY KEEN:  We will not let you lie to our children.

01:59

SOCIAL MEDIA CLIP:  This is the Nazis, look at the Nazis, look at the Nazis.

PATRICIA KARVELAS:  I want to understand why medical interventions

02:02

Super: Patricia Karvelas

for young transgender people have become such a battleground. Is it right to provide puberty blockers and hormones?  Is enough caution being exercised?  And is this model the life saver its supporters say it is?

02:11

Title: BLOCKED

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02:26

Brock intro, sitting on bed

BROCK WILLCOCKS: I'm Brock Willcocks. I'm a 14-year-old trans girl, and I live in the western part of Sydney. "

02:37

Brock applies make up

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02:44

BROCK WILLCOCKS: I started realising that I was different, mainly in primary school. I always imagined myself having long hair and putting on makeup and wearing dresses, I would always be like, "Oh, I wish I was a girl."

02:54

Brock 100%

But I would be disappointed to find out, "Oh, you're a boy. You have to stay like this."

03:13

Home video, Brock as younger child

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03:19

Photo. Brock as younger child, dressing up

RENEE WILLCOCKS: I suppose the first thing that we noticed in preschool, I'd come and pick her up and she'd be a princess and dressed up and

03:27

Renee 100%. Super:
RENEE WILLCOCKS

pushing a pram and wearing the fake high heels and not really your kind of typical rough house boy.

03:39

Brock staring into mirror

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03:45

PATRICIA KARVELAS: As puberty kicked in, the flamboyant confident kid became withdrawn and depressed.

03:48

BROCK WILCOCKS:  I tried going to therapy to try and explain this and try to be like, why do I feel like this?  It's not about going to therapy to fix it

03:55

Brock 100%

PATRICIA KARVELAS: How do you know weren't influenced?

04:03

BROCK WILCOCKS:  I wasn't influenced by a trans person. I did not know any trans person growing up at all. Not one trans person, not even anyone on any sort of social media.

04:05

Brock staring into mirror

PATRICIA KARVELAS: Brock kept it to herself. She knew that her mum was sceptical about transgender issues. 

04:21

RENEE WILLCOCKS:   I was hearing all these different things in the media and when the debate came up about a point

04:28

Renee 100%

with the pronouns, and I kind of, yeah, I said, "Why should we be catering to these people? If they're identifying, if I can see biologically they're a male, I'm going to say that they're a male.

04:34

Brock staring into mirror

PATRICIA KARVELAS: In Year 8 Brock found the courage to tell her mum through a text message. 

04:49

Brock 100%

BROCK WILCOCKS: She opened my bedroom door and I just saw that she was in tears and she started just apologising to me. And the reason she was apologising to me was because, in the past, she wasn't the most accepting person of being trans. She just was crying to me and apologising for everything that she had said, just everything and anything.

04:55

RENEE WILLCOCKS: it was the first time that I'd really seen Brock show

05:22

Renee 100%

what she's been going through. And it was just so hard to see, because it was just such raw emotion and she just hates her body and can't stand to look at herself.

05:26

Renee preparing food with Brock

PATRICIA KARVELAS: Renee was determined to support Brock, but she struggled to find help.

05:45

RENEE WILLCOCKS: We called Westmead Children's Hospital; they couldn't help us.

05:54

Renee 100%

So even though Brock is a child, they do draw a line in the sand for certain developmental milestones. In Brock's case, it was because Brock's voice had already broken.

05:57

Renee preparing food with Brock

PATRICIA KARVELAS: Renee turned to another New South Wales Health run clinic, Maple Leaf House in Newcastle.

RENEE WILLCOCKS: When I spoke to them on the phone and they said that they could help me

06:10

Renee 100%

despite the milestone that Brock had already achieved, I broke down and cried. It was such a relief.

06:23

Brock and Renee preparing food

PATRICIA KARVELAS: A psychiatrist diagnosed Brock with gender dysphoria. Gender dysphoria refers to the psychological distress experienced by those whose gender identity doesn't match their biological sex. Brock started treatment known as gender affirming care, which is an established medical practice across Australia.

06:29

It starts with a multidisciplinary assessment and can progress to medical intervention. Brock was prescribed puberty blockers to stop her developing as a young man.

06:53

RENEE WILLCOCKS: Obviously, you wouldn't want to rush into treatment when you're just finding out that your child is transgender. 

07:03

Renee 100%

For us, it made sense. The fact that Brock had been going to a psychologist for quite a while was reassuring to know that it's not a phase, so to speak. But when you're at that age of 13, development's fast. 

07:10

Renne and Brock cooking

RENEE: "Do you want to spray them with olive oil or something?"

07:31

BROCK: Doesn't say that in the TikTok… that's where I got the recipe from.

PATRICIA KARVELAS: The Maple Leaf clinicians told Brock's family the blocking effects are reversible, but they warned about the potential side effects which can include reduced bone density.

07:34

RENEE WILLCOCKS: The fact that Brock is now 14 and won't have to be on blockers for a lengthy period of time, I suppose that relieves a lot of concern that we had.  

07:54

Renee 100%

But it's definitely something that we've had to weigh up, and we're okay with that, we're okay with that risk.

08:03

Brock shows jewellery

BROCK: These are just all my rings and earrings.

08:11

PATRICIA KARVELAS: Brock will soon have her third injection of puberty blockers. She says she is relieved she's stopped developing into a body that she doesn't identify with.

08:15

Brock shows clothes

BROCK: This jacket, love, love this jacket.

08:25

PATRICIA KARVELAS: She no longer hides the clothes she wants to wear.

08:28

BROCK: And it's just makes me feel rich and fashionable.

08:31

High school hall. Night drama class. Brock in class

DRAMA TEACHER: "When I say go, I want you to act like you are an angry customer in a shop. Go."

BROCK in drama class: "Thank you."

BROCK:  I 'm really into theatre and drama.

"Do any of you work here? My coffee is cold."

BROCK:  You get to pretend to be someone else, which is almost like what I've been doing all my life. 

DRAMA TEACHER: "Ladies and gentlemen – Brock."

08:35

BROCK WILLCOCKS: By November I should hopefully be starting hormones, which is really something that I feel I need. Not want. I feel I need.

09:10

PATRICIA KARVELAS: Cross sex hormones are often the next stage of gender affirming care. Daily pills or patches of oestrogen would mean that Brock would slowly start looking more feminine and develop breasts and hips. The physical changes from cross sex hormones are irreversible.

09:22

Brock brushing her hair

RENEE WILLCOCKS: The choice was, allow Brock to live a life in true authenticity, potentially very happy life, and hopefully a long life. When you weigh the prospect up,

09:41

Renee 100%

and what's the alternative? Potentially not having a child. Brock was literally planning her death. What choice do we have?

09:56

Brock applying makeup

BROCK WILCOCKS: I didn't choose to be born in this body and then want to be born in another. That's not a choice that I just made. I didn't wake up one day and be like,

10:08

Brock 100%

"Yeah, I'm trans." No, it was years of dysphoria, self-hate, that it took me to find out you're not in the right body.

10:16

Person on scooter

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10:30

PATRICIA KARVELAS: Referrals to Australia's seven publicly funded Gender Services are ballooning. Since it first opened 10 years ago

10:33

Onscreen text:
ROYAL CHILDREN'S HOSPITAL
3,370 referrals
62% females assigned at birth.

Melbourne's Royal Children's Hospital had had more than 3,300 referrals - 62% of those were females assigned at birth.

10:41

Onscreen text:
ROYAL CHILDREN'S HOSPITAL
1,095 patients in 2022
WESTMEAD CHILDREN'S HOSPITAL
145 patients in 2022

Last year they had 1,095 patients, seven times as many as the Westmead Children's Hospital Gender Service in Sydney.

10:51

Child painting nails. Onscreen text:
Queensland CHILDREN'S HOSPITAL
642 on waitlist

Wait lists are long, latest figures show the Gender Service at Queensland's Children's Hospital has more than 600 patients waiting for a first appointment.

11:00

Ext. Westmead Children's Hospital

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11:14

PATRICIA KARVELAS: A feud over how to treat

11:19

Karvelas to camera

kids with gender issues is playing out at Westmead Children's Hospital in Sydney's west. It's a feud the hospital hierarchy has tried to keep under wraps, but a few former Westmead staff have been brave enough to help us tell this story.

11:20

Ext. Westmead Children's Hospital

They've told us there are deep divisions over how to help kids with gender distress.

11:37

Photo. Ashley as child

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11:47

ASHLEY:   When I started puberty, I got really depressed.

11:52

Ashley 100%. Super:
ASHLEY

I was super anxious about myself, how I was looked at by people. It was a really hard time for me.

LANNEN DONNELLY, Ashley's mother:  Westmead Hospital saw Ashley urgently

11:55

Lannen 100%. Super:
LANNEN DONNELLY
Ashley's mother

and prioritised consultation with him because he was self-harming. His mental health had deteriorated rapidly.

12:14

Photos. Ashley in hospital

PATRICIA KARVELAS: Ashley was prescribed puberty blockers in 2015. His mother agreed that he could be part of emerging research on gender distress conducted by clinicians at the hospital. It was this research that laid the foundation for a series of peer reviewed papers published between 2021 and 2023.

12:21

Photo. Ashley having necktie tied

Recent frontline staff at the Gender Service were not involved.

12:46

Lannen 100%

LANNEN DONNELLY: It was really important to me that we were able to share this experience with researchers to be able to help with the way forward. Let's show that you know trans kids are a natural, normal part of every society on earth.

12:51

Westmead hospital exteriors

PATRICIA KARVELAS: Ashley's mum, Lannen never anticipated how events would unfold. The Westmead research papers would be weaponised by outside opponents to gender affirming care.

13:06

Onscreen text:
"high rates of adverse childhood experiences…"
"family conflict"
"parental mental illness"
"loss of important figures via separation"
"maltreatment was also common"

In 2021 Westmead researchers published a peer reviewed report examining the clinical characteristics of 79 young people seeking help at the Gender Service. They pointed to complex family trauma amongst many of those reviewed:  "high rates of adverse childhood experiences" including family conflict, parental mental illness and loss of important figures via separation.  A history of maltreatment was also common . They stopped short of finding a causal link.

13:21

Onscreen text:
"a trauma-informed model of mental health care"
"clinicians (including ourselves)... are coming under increasing pressure to compromise their own ethical standards… by engaging in a tick the box treatment process."

They argued going straight to the gender affirming model is dangerous and said, "a trauma-informed model of mental health care" should be included in all gender care clinics.  They said "clinicians (including ourselves)... are coming under increasing pressure to compromise their own ethical standards… by engaging in a tick the box treatment process".

13:55

Dr Ravine at microscope

Genetic pathologist, Dr Anja Ravine was watching on from another part of the hospital. As a transgender woman herself she was curious about the research showing family trauma amongst young transgender people.

14:18

DR ANJA RAVINE, Genetic pathologist: The implicit messaging that I read in this -- which actually wasn't said directly, but it was implicitly there and quite powerful -- is that these children,

14:34

Dr Ravine 100%. Super:
DR ANJA RAVINE
Genetic pathologist

trans-ness and presentation with associated distress is really something that's emerged out of a background of early childhood traumas, poor parenting practices, associated impaired parent/child attachment patterns. These papers have all the badges that you'd expect, you know, they're credentialed, and people look to those credentials.

14:47

Ashley and his mum at table

PATRICIA KARVELAS: Ashley's mum, Lannen read it as parent blaming.

15:16

LANNEN DONNELLY:  The report from Westmead seemed to allude to, kids are trans

15:21

Lannen 100%

because of their depression. Kids are trans because of dysfunction in the home. That was horrific to read, for me, because we had dysfunction in the home and Ashley had depression because we weren't getting help with him being trans. 

15:25

Anna on train

15:48

PATRICIA KARVELAS: In late 2022, Anna started as a clinical psychologist at the Westmead Children's Gender Service. 

15:54

It was early in her clinical career, and she was committed to helping young people who were in distress. 

16:01

ANNA, Clinical psychologist: I was very passionate about helping these

16:07

Anna 100%. Super:
ANNA
Clinical psychologist

trans youth that have, you know, one of the highest rates of suicidality, and difficulties, and, you know, social stigma still, and difficulties at school. And I wanted to be able to provide ongoing support where I could really hear them, validate them, and help them through their journey.

16:11

Anna alights from train

16:35

PATRICIA KARVELAS: But she was finding it hard to do her job.

ANNA, Clinical psychologist: I didn't feel supported. I felt that the environment was very difficult. I think one of the main issues was the long wait list, the lack of staff.

16:40

Anna 100%

Our model of care was being developed to become a better, improved model of care. But it was never finalised, it was never -- 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.

16:56

Phone video. Noah piggybacking child

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17:26

PATRICIA KARVELAS: Noah O'Brien was on that waiting list. Noah was 14 when he first told his mother he identified as a boy.

17:35

Photo. Noah with guitar

LAUREN O'BRIEN, Noah's mother: We kind of thought that maybe it was a friend influence, or someone online, or something like that.

17:48

Lauren 100%. Super:
LAUREN O'BRIEN
Noah's mother

But the longer that time went on, we just saw, no, it was definitely just him, who he was.

17:55

Photo. Noah with dog and cat

PATRICIA KARVELAS: Noah asked to go to the GP to find out about puberty blockers.

LAUREN O'BRIEN: We didn't realise at that point that he was already

18:02

Lauren 100%

going through the beginnings of the eating disorder. So, he was taking that matter into his own hands to stop his own periods and stop his breast growth through not eating.

18:12

Photos. Noah in hospital room, wearing mask

PATRICIA KARVELAS: We can't know for sure what exactly caused Noah's eating disorder, but research has shown that eating disorders are often associated with gender dysphoria.

18:27

Noah's food refusal got worse, and he ended up at Westmead Children's Hospital. He was discharged the next day. 

LAUREN O'BRIEN: They thought it was not an eating disorder, that perhaps it was gender related and that they had put in

18:39

Lauren 100%

his discharge papers that our GP needed to make a referral for the gender centre.

18:56

Exteriors. Westmead Children's Hospital

PATRICIA KARVELAS: The GP sent the referral last October. Noah's family didn't know he would be pushed way down the waiting list at the Westmead Hospital Gender Service because it deprioritises children who are well advanced into puberty.

19:02

Photo. Noah and grandmother

An insider has told Four Corners it could have been a year before Noah was seen.

ROSE MARSH, Noah's grandmother: Her child had a problem, it needed to be fixed.

19:21

Rose 100%. Super:
ROSE MARSH
Noah's grandmother

So, 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.

19:31

Photos. Noah in hospital.

PATRICIA KARVELAS: As Noah struggled with gender issues, his eating disorder also got worse.  He was readmitted to Westmead Children's Hospital and treated for anorexia. There was still no gender focused care for Noah apart from this:

19:51

Lauren show materials gender materials provided by hospital

LAUREN O'BRIEN: So this this is the bag that was given to Noah when he was in hospital and it had some print outs from the internet, medical guidelines about gender diverse and treatments. There's stuff about gender diverse musicians, some stickers, a place in Blacktown that you can go to, legal services and a few little things in here, but nothing that linked to the hospital, nothing that gave us any sort of direction of where to go next. And again, it's paper, it's not a person saying this is what we're going to do to help, we're here with you.

20:13

Photo. Noah in hospital

PATRICIA KARVELAS: Four Corners has learnt that it was a social worker from the Gender Service who visited Noah. 

20:57

Email from social worker. Onscreen text:
"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 later wrote an email saying this: "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?"  But that discussion didn't go ahead.

21:05

Onscreen text:
"cease ...involvement with Noah due to the eating disorder being the primary focus"

A senior staff member from outside the Gender Service told the social worker that she needed to "cease ...involvement with Noah due to the eating disorder being the primary focus".

21:24

Photo. Noah in hospital

Noah was effectively denied specialist gender support.

ROSE MARSH, Noah's grandmother: It was very, very confusing.

21:35

Rose 100%

It was almost like they walked in and said, okay, this is a gender issue. Here, take this bag and go research and go from there.

21:45

Phone footage. Noah in hospital corridor

PATRICIA KARVELAS: After nearly four weeks in the eating disorder unit, Noah was sent home.

21:55

Photo. Noah with tube

His discharge summary included gender dysphoria. He was still on the waiting list.

ROSE MARSH, Noah's grandmother: I think Noah should have at least seen somebody that could help him

22:02

Rose 100%

with his gender issues and sort of set a course of action that could be followed up and monitored, but there was just nothing.

22:14

Photo. Noah in park

PATRICIA KARVELAS: This year's summer holidays were drawing to a close and Noah was anxious about returning to school. He would be wearing a boy's uniform for the first time.

22:28

Lauren 100%

LAUREN O'BRIEN: I think he was just worried about how people would react to him presenting at school as Noah. I think he felt like they would see him as the person that had been in their class before as Lily, and that somebody might say something or that they might think he's a fraud.

22:40

Family photos.

PATRICIA KARVELAS: And then the unthinkable happened.

ROSE MARSH: About quarter past 12, the phone rang and I thought,

22:59

Rose 100%

oh, it's Lauren. And so, I picked it up and went, "Hello". Sort of just, what are you still doing awake? And that's when she said "It's Noah".

23:11

Lauren 100%

LAUREN O'BRIEN: My husband gave him CPR. And the ambulance and the police arrived about four minutes after we called them.

23:23

They took him to Westmead Hospital, where he stayed alive until six in the morning. That was from about 11 o'clock. So, we got seven hours to actually say goodbye.

23:35

Noah 100%

ROSE MARSH: I think Noah didn't want to be a girl, but I feel like he didn't get any help or support in making that transition to become a male. I mean, 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.

23:49

Lauren 100%

PATRICIA KARVELAS: If there had been doctors from the Gender Service being able to see Noah, do you think that would've made a difference? I mean, we can't know.

LAUREN O'BRIEN: Definitely, I think if they had have been speaking to him and found out what he needed, I think it definitely would've changed things.

24:15

Photo. Noah

Music

24:32

Exteriors. Children's hospital

PATRICIA KARVELAS: It wasn't long before news of Noah's death reached the frontline clinicians at the Gender Service.

ANNA, Clinical psychologist: I think the core team was incredibly distressed

24:39

Anna 100%. Super:
ANNA
Clinical psychologist

and felt completely helpless. I can't speak for them, but I know I felt helpless, and I felt just extreme angst and sadness for this family that were on this wait list. And it just showed that, yes, it happens, the suicidal ideation is high, and sometimes it does eventuate into suicide.

24:54

Hospital exteriors

PATRICIA KARVELAS: In the wake of Noah's death, a paediatrician at the Gender Service asked Westmead Children's Hospital to make changes to help high risk patients, but she saw no change.

ANNA: I think if that had happened and

25:17

Anna 100%

there'd been a great change in the service for the better, and we were able to help more people in a more timely manner, that would've been great, some silver lining, but nothing changed. So, we were just left feeling sad, and helpless, and not able to make any positive changes going forward really.

25:32

GFX. Photo. Noah/Hospital exterior. Onscreen text:
"our 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."

PATRICIA KARVELAS: Westmead Children's Hospital issued a statement offering "our 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."

25:54

Hospital exteriors

PATRICIA KARVELAS: For months they've declined to answer specific questions about the Gender Service. 

26:16

Onscreen text:
Government Information (Public Access) Act 2009
Notice of Decision

Four Corners has obtained Freedom of Information documents which show Westmead Children's Gender Service is taking on very few new patients.  

26:22

Onscreen text:
NEW PATIENTS
2023 Up to 1 June - 3
2022 – 88
ACTIVE PATIENTS IN 2022
Westmead Children's Gender Service – 145
"continues to provide holistic, culturally safe and affirming care to current patients"

Up to June this year it's taken on just 3 compared to 88 last year.  The most recent data shows the Westmead service had 145 active patients last year. Westmead  Children's Hospital says it "continues to provide holistic, culturally safe and affirming care to current patients".

26:32

Children on various devices

Music

26:54

Onscreen text:
"rapid-onset, or adolescent-onset GD"

PATRICIA KARVELAS: Westmead's latest research paper was published in February this year and this one would have the greatest impact. The paper highlighted increasing rates of what's known as "rapid onset gender dysphoria" particularly amongst a small subset of adolescent girls. It's a contested concept. The paper speculates it's caused by "some evolving social process".

26:58

Dr Kenny 100%. Super:
DR DIANNA KENNY
Consultation psychologist

DR DIANNA KENNY, Consultant Psychologist: If a young person has been exposed to the ubiquitous media onslaught on both social media and the internet, and also, you know, in peer groups at school, in rainbow clubs and so on, there are the vulnerable young people who will be drawn in to that sphere of thinking that they're transgender.

27:24

Kenny at computer in office

PATRICIA KARVELAS:  Psychologist, Dianna Kenny is an ambassador for Binary, a lobby group which campaigns against so called "gender ideology". She treats adolescents with gender distress in her clinical practice.

27:52

Dr Kenny 100%

DR DIANNA KENNY: The approach is essentially a psychotherapeutic approach that helps the young person and his or her family understand all of the complex dynamics that have resulted in the young person experiencing gender dysphoria.  It is not conversion therapy. It provides a safe exploratory space for children to look at themselves and to gain a greater understanding."

28:06

Onscreen text:
DESISTANCE
"…disappearance of gender related distress"
22.1%

PATRICIA KARVELAS: One of the most controversial findings in the latest Westmead research relates to the concept of desistance, and the rate of desistance is often used as an argument against gender affirming care.  The Westmead researchers define desistance, as the "…disappearance of gender related distress" that brought the young person to the clinic. They reported that gender distress eventually disappeared for 22 per cent of those they studied.

28:41

Ravine 100%. Super:
DR ANJA RAVINE
Genetic pathologist

DR ANJA RAVINE: For the general public, the child has desisted, they're no longer trans would be what you would think. But when you read the papers, there's actually a variety of definitions. When you look carefully at where that 22% comes from, it includes children who are originally assessed and considered not to meet the diagnostic criteria, so they were never eligible for referral on consideration of pubertal blockade. And that was the majority of them and there were others as well.

29:16

Hickie 100%. Super:
PROF. IAN HICKIE
Brain and Mind Centre, University of Sydney

PROFESSOR IAN HICKIE, Brain and Mind Centre of the University of Sydney: 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.

29:51

Onscreen text:

"the desistance rate in the sub-group who met diagnostic criteria… was 9.1%"
"The evidence base… the gender affirming medical pathway is sparse and for the young people may regret their choice... the risks for potential harm are significant."

PATRICIA KARVELAS: The report also stated that  there was a 9.1 per cent desistance rate amongst those who were diagnosed with  gender dysphoria. The report concluded, "The evidence base for the gender affirming medical pathway is sparse and for the young people may regret their choice..... the risks for potential harm are significant."

30:09

Spencer 100%

PATRICIA KARVELAS: When that last Westmead research was published, what was your reaction?

30:33

DR JILLIAN SPENCER, Child and adolescent psychiatrist:  The researchers had taken the effort to really convey the issues at hand.

30:39

Super:
DR JILLIAN SPENCER
Child and adolescent psychiatrist

It became clear to me that they really wanted to try and assist Australia to come to terms with this issue by explaining everything. And that made me happy because I really wish that we would be able to talk about this, because it's a child protection issue.

30:45

Anna 100%

PATRICIA KARVELAS: What happened inside the culture of the clinic after that paper was published?

31:04

Super:
ANNA
Clinical psychologist

ANNA: I think there was a lot of distress. It felt chaotic in that instead of families calling about appointments, they were calling to raise their concerns and their distress. It was very difficult for the staff as well.

31:07

Anna in café

PATRICIA KARVELAS: Two months after the final research was published, Anna decided to resign.

31:32

ANNA: I left feeling defeated. I think there was so much I wanted to do,

31:40

Anna 100%

and it's such a high need area. These kids and these adolescents are struggling.

31:46

US trans support event

31:53

PATRICIA KARVELAS: The Westmead research landed amid an increasingly polarised global debate over gender affirming care.

32:00

Anti DeSantis rally

CROWD CHANT: "Trans lives matter."

32:06

PATRICIA KARVELAS: At least 20 U.S. states are moving to ban or restrict gender affirming care for young people.

32:12

Trans rally

32:21

DeSantis signs legislation

RON DESANTIS, Governor, Florida: "This will permanently outlaw the mutilation of minors.  It will outlaw the surgical procedures and experimental puberty blockers for minors."

32:24

Donald Trump

DONALD TRUMP: "The left-wing gender insanity being pushed on our children is an act of child abuse."

32:36

Tavistock Centre exteriors

PATRICIA KARVELAS: In the UK, the long running Gender Service at London's Tavistock clinic has been accused of rushing patients into taking gender affirming drugs.

32:41

DR DIANNA KENNY: A number of clinicians who were working there became very concerned about

32:54

Dr Kenny 100%. Super:
DR DIANNA KENNY
Consultant psychologist

the treatment that young people were receiving, believing that they weren't being assessed properly, before being placed on a medicalised pathway.

33:00

Tavistock Centre exteriors. Onscreen text:
"there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment."

PATRICIA KARVELAS: On the back of this, the UK National Health Service has restricted puberty blockers to children in clinical trials stating, "there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment."

33:11

Prof. Hickie 100%. Super:
PROF. IAN HICKIE
Brain and Mind Centre, University of Sydney

PROF. IAN HICKIE: What went wrong at the Tavistock clinic is to get stuck in one particular point of view. So what happened, people working there simply said it's more complex and we need to have services that understand that complexity and also respond in real time. We can't just in a cookie cutter way, do the same thing for every kid, It was not about that the approaches were intrinsically wrong. It was bad management of the complexity of the kids coming forward. And I think there's an important learning out of the Tavistock, how to do it wrong.

33:28

Finland GVs

PATRICIA KARVELAS: European countries like Norway, Sweden and Finland that once embraced puberty blockers have also wound them back.

DR DIANNE KENNY, Consultant psychologist: I've just returned from Finland, from

33:55

Kenny 100%

an international conclave on the psychotherapy of children with gender dysphoria. And in 2020, they withdrew their support for gender-affirming treatment as the first line of treatment for this group of young people, and have reverted to a psychotherapeutic approach.

34:08

Queensland Children's Hospital exteriors

PATRICIA KARVELAS:  The global scrutiny of medical intervention is placing increasing pressure on Australian gender clinics to show what they do is evidence based.

34:31

Dr Stathis interview

Dr Stathis thanks for agreeing to talk to us.

34:43

DR STEPHEN STATHIS:  Thank you; it's an important issue.

PATRICIA KARVELAS: Dr Stephen Stathis oversees the Gender Service at the Queensland Children's Hospital, which last year had 922 active patients.

Stathis 100%. Super:
DR STEPHEN STATHIS
Child & Youth Mental Health Services, Children's Health QLD

DR STEPHEN STATHIS: About 80% of the research on gender-affirming care has been published in the last 10 years. So, 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.

35:00

For instance, there's increase in evidence that puberty blockers impact on bone mineralisation, problems with the bones, so we're adapting our recommendations and our consent forms to take that into account.

35:21

Surfing, beach GVs

Music

35:35

Sapphire walks on beach

PATRICIA KARVELAS:  Sapphire is receiving care at the Queensland Children's Hospital's Gender Service.

SAPPHIRE: I'm 10, I'm in Grade 5, and I see myself as a very energetic and joyful child.  I want people to see me as a proud transgender girl, I'm a girl and that's who I am and that's who I will always be.

35:47

Sapphire playing board game

ALISON, Sapphire's mother:  My youngest child, from a very early age, demonstrated what I now know as gender nonconformity. She was born as a male,

36:19

Alison 100%

assigned male at birth and was always drawn to stereotypically feminine clothing, activities.

36:33

Sapphire playing board game

SAPPHIRE: I knew that I wanted to be a girl and I was a girl, but I didn't really know what to say or how to say it or if it was true.

36:42

PATRICIA KARVELAS: Back then the family lived in Sydney. In grade 3 Sapphire was struggling because of bullying at school and her mum noticed she was becoming increasingly sad and withdrawn.  Alison sought help from the Westmead Children's Gender Service.

36:56

Alison 100%

ALISON:  There in fact were no mental health services available at the clinic, which was very distressing and illustrated that the Westmead clinic was not offering a complete model of care. So when I investigated the gender clinics in interstate, both in Melbourne and in Brisbane, the comparison between the services is night and day.

37:15

Sapphire reading

PATRICIA KARVELAS: Alison decided to move her family to support her youngest child.

37:40

ALISON: We were forced to relocate states. We were forced to leave New South Wales for Queensland in order to pursue affirming care. 

37:49

Sapphire

SAPPHIRE: I'll be on puberty blockers soon and that's just going to be pausing really my body from growing into what I don't want it to be. I guess, throughout my life I've felt more and more like this isn't me. The body that I'm in, I don't want to be in this anymore.

37:58

Alison interview

PATRICIA KARVELAS: One of the critiques of affirming care is that it is too affirming, if I can be blunt, it doesn't do enough exploration. What's your response to that in terms of your lived experience?

ALISON: I think that transgender children are exploring themselves on a daily basis, and that level of introspection is present every single day of their lives.

38:28

And that if they are provided with unequivocal love and support then that inner dialogue that they have been having with themselves, they can then have with educated health professionals. It is an ever-present issue that we face every single day. It is the very core of my child's being and it is unwavering.

38:52

Alison cuts up apple for Sapphire and friend

DR STEPHEN STATHIS: These families need our support. What the gender-affirming model says is that we affirm where a young person is.

39:19

Stathis 100% Super:
DR STEPHEN STATHIS
Child & Youth Mental Health Services, Children's Health QLD

It doesn't mean that we are locked in to treating a young person with puberty blockers or hormones. It doesn't mean that we are stuck in some ideology. What it does mean is that we're curious and we're keen to explore the reasons why they've presented.

39:36

PATRICIA KARVELAS:  There is a high-profile case of a psychiatrist at your hospital who is under review in relation to her views on transgender care for children. What's going on at this hospital? 

39:56

DR STEPHEN STATHIS: Well, I can't comment on the specifics of that case. What I can say is that I welcome open debate across the psychiatry community and with the consultants in the hospital about a whole range of views.

40:07

Queensland Children's Hospital exterior

PATRICIA KARVELAS:   The Queensland Children's Hospital has stood down a senior psychiatrist from clinical duties pending an investigation over a complaint from a young transgender patient.

40:25

Computer screen. Spencer at computer

Dr Jillian Spencer is contesting the allegations and has lodged a complaint with the Queensland Human Rights Commission saying as a doctor she should have a right to object to the affirmation model.

40:38

Spencer 100%. Super:
DR JILLIAN SPENCER
Child and adolescent psychiatrist

DR. JILLIAN SPENCER: I can't comment on my own situation because of the code of conduct, but what I can tell you is that I think the vast majority of child and adolescent psychiatrists have serious concerns about the affirmation model.

40:50

Rally on Parliament House lawn

CROWD CHANT:   "We will fight, we will win, put the bigots in the bin…"

41:01

Keen addressing rally. Super: YouTube video

KELLIE–JAY KEEN: "Transitioning children is profound abuse."

41:11

PATRICIA KARVELAS: When anti trans activist Kellie-Jay Keen held a rally in Canberra earlier this year, Dr Jillian Spencer joined her on the podium to warn about gender affirming care for young people.

41:18

Spencer addresses rally

DR JILLIAN SPENCER: "Anyone's child, yours or mine, will be encouraged at school, online, during extra-curricular activities, by their friends and by health professionals, to contemplate their gender."

41:30

PATRICIA KARVELAS: The hospital has told Dr Spencer she allegedly broke the Queensland Public Service's code of conduct through her public statements.  She contests this and says she was speaking in a private capacity.

DR JILLIAN SPENCER: "There are massive health risks from these medications and surgeries. We must speak out about the harms we see being done to women and children from gender ideology."

41:44

DR JILLIAN SPENCER, Child and adolescent psychiatrist: I think after the years of pressure and not being able to express these concerns,

42:12

Spencer 100%

I just felt that I couldn't miss an opportunity to say them out loud. It's a really hard thing as a doctor to be in a position where you feel that you need to do an intervention that you don't agree with. Being able to speak aloud about it was a relief.

PATRICIA KARVELAS: Dr Spencer is calling for a federal inquiry into the gender affirmation model for young people.

42:17

DR. JILLIAN SPENCER: I worry about the harm to children and of concern is the knowledge that it is much more common for children who later will be gay or lesbian to show cross-sex identification and gender dysphoria in childhood. So, there is that worry there that we're changing the trajectory of those children. My main concern with puberty blockers is that they stop the healing of the gender dysphoria that naturally occurs through the course of adolescence that we know from the old studies.

42:46

Children GVs

PATRICIA KARVELAS:  Dr Spencer points to the prevalence of other issues like autism, ADHD and depression.  Rather than medical intervention she urges what's known as watchful waiting.

43:18

Spencer 100%

DR JILLIAN SPENCER: Watchful waiting is a medical term which tended to describe taking time to see if a problem resolves before intervening. But in terms of a watchful waiting approach for children with gender dysphoria, 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.

43:30

Hickie 100%. Super:
PROF. IAN HICKIE
Brain and Mind Centre, University of Sydney

PROFESSOR IAN HICKIE: There's no evidence that exploratory therapy, simple psychological therapy is a legitimate alternative to what is being offered through most of our specialist clinics in Australia.  Exploratory psychological therapies, family therapies instead, watchful waiting are not evidence-based. They are the sets of intrinsic beliefs of different professional groups.

44:06

Courtney dressing and recording YouTube video

PATRICIA KARVELAS: There's a new front in the battle over gender affirming care and it involves destransitioners.

44:25

COURTNEY COULSON: Clap sync. My name is Courtney Coulson, a female to male to female detranstioner and on this channel we try to figure out what the hell is wrong with me.  On this episode, why did I want to be a man?

44:39

PATRICIA KARVELAS: Courtney Coulson started testosterone treatment in her early 20s; she shares her story on her YouTube channel.

44:51

COURTNEY COULSON: I think you can be pushed so far into a belief that these things start to become real and this other identity becomes real. 

44:59

Photo. Courtney

I just went right through the trans sort of production line

45:07

Courtney 100%. Super:
COURTNEY COULSON

and I stayed living as a man for five years. 

45:14

Courtney looking in mirror

PATRICIA KARVELAS: COVID lockdown meant she couldn't go ahead with planned chest surgery and eventually she stopped taking cross sex hormones.

45:20

COURTNEY COULSON: I stopped taking testosterone,

45:27

Courtney 100%

and then my brain and body just sort of balanced itself out. Whatever I was going through when I wanted to transition, I seemed to have outgrown and gotten over it.

45:30

Courtney by mirror

DR DIANNA KENNY: We don't have good data on the number of detransitioners,

45:42

Kenny 100%. Super:
DR DIANNA KENNY
Consultant psychologist

but what we do know is that there are an avalanche of young people coming out and talking about their experiences. And people as young as 18, 19, early 20s are warning their younger peers, "Don't make the mistake that I've made. I'm going to regret this for the rest of my life."

45:49

Detransition subreddit page

PATRICIA KARVELAS: Research on those who regret transitioning is still emerging. Supporters of gender affirming care put it at around 1%.  But the voices of those who regret medical intervention are growing louder.  

46:12

Courtney 100%

COURTNEY COULSON: Before you commit to this thing for the rest of your life, don't you want to see every perspective? I should have been able to do that, and I didn't.

46:27

Royal Children's Hospital exteriors

PATRICIA KARVELAS: Melbourne's Royal Children's Hospital pioneered gender affirming care in Australia.  For the last few years, leaders of the service have kept their heads down as the anti-trans sentiment became more ferocious and politicised.

46:37

Karvelas walks into hospital

They've decided they can't stay quiet any longer.

46:54

Nguyen interview in hospital

DR TRAM NGUYEN, Co-lead and lead psychiatrist, The Royal Children's Hospital Gender Service:  There's lots of misinformation out there and it affects young people that we see. We don't have anything to hide, because we're really strong on what we do and the evidence behind it.

46:59

Nguyen 100%. Super:
DR TRAM NGUYEN
Lead psychiatrist, The Royal Children's Hospital Gender Service

Some of those who are critical of the gender-affirming approach almost assume that we blindly only look at gender and we don't. People are complex and we look at all aspects. We do take a biopsychosocial history and a developmental history and we really consider what are the coexisting physical and mental health aspects, and what we try and look at addressing all of them or what is the most prominent and urgent at that point in time.

47:09

Gender Service team meeting

DR CATE RAYNER: "So, we all know that our waitlist continues to be long and it's a kind of difficult responsibility and burden that we all hold and we're working really hard to develop supports for those on the wait list."

47:41

PATRICIA KARVELAS: The multi-disciplinary team includes psychiatrists, psychologists, paediatricians and nurses.

47:54

DR TRAM NGUYEN:  It's not one session and you get hormones,

48:01

Nguyen 100%

that's a total misconception about what we do. People can come to us and it can be months and years depending on how old and what developmental stage they're at before there is any medical treatment, if there is. We talk through at length with both a medical and a mental health clinician regarding reversible and irreversible effects. We talk about fertility, we talk about regret, we talk about changing your mind. We don't shy away from any of those hard questions.

48:04

Ken Pang on laptop

PATRICIA KARVELAS: Paediatrician Ken Pang is leading long term research examining outcomes for young people attending the Melbourne clinic

48:35

Pang 100%. Super:
DR KEN PANG
Paediatrician, The Royal Children's Hospital

DR KEN PANG, Paediatrician, Royal Children's Hospital: What we are aiming to do is to look at their long-term mental and physical health outcomes having received gender affirming care at our hospital. We're also looking at things such as bone health.  We're looking again at things like mental health before and after puberty blockers, before and after gender affirming hormones in the form of oestrogen and testosterone.

48:47

PATRICIA KARVELAS: There's a war on the actual research. How do you navigate that and provide the best standard of evidence? 

49:04

DR KEN PANG: I don't feel like there's a war of research when it comes to robust evidence-based rigorous research. I think that in terms of the war of opinion, as with many issues, lots of people have opinions, but what's problematic is that sometimes people who voice those opinions don't actually have any expertise in the area.

49:12

Gender Service team meeting

DR CATE RAYNER: "There's been a lot in the media and on social media at the moment that really doesn't align with our practice here at the Gender Service."  

49:34

Nguyen in team meeting

PATRICIA KARVELAS: Dr Tram Nguyen fears the needs of young transgender people are being misunderstood. She's especially worried by the impact of the recent research from Westmead Children's Hospital...  Dr Nguyen is one of seven senior adolescent clinicians from around Australia who have published a critique rejecting the conclusions of the Westmead research.

DR TRAM NGUYEN:  We are not a group of clinicians or researchers

49:43

Nguyen 100%

who do this regularly, but for us, we just felt that there was a moral obligation

50:13

PATRICIA KARVELAS: These are senior clinicians who've done long term research; what makes you so sure that their conclusions are wrong?

50:19

Nguyen 100%. Super:
DR TRAM NGUYEN
Lead psychiatrist, The Royal Children's Hospital Gender Service

DR TRAM NGUYEN: A number that has been quoted in other media outlets is 22% of young people in that study desisted and 22% is a really alarming figure. It's alarming to young people, to parents and clinicians and clinicians who don't work in the field. But when we look at the raw numbers, the 22% is actually incorrect.

50:26

Stathis 100%

PATRICIA KARVELAS: You, alongside other doctors across the country, signed a letter with other doctors sharing your concerns about the Westmead research. Why did you decide to do that?

50:50

Stathis 100%. Super:
DR STEPHEN STATHIS
Child & Youth Mental Health Services, Children's Health QLD

DR STEPHEN STATHIS: Because I believe that we need balanced research. And I believe that in that article there were flaws that need to be corrected.

51:00

Westmead exteriors

PATRICIA KARVELAS:  Four Corners has tried many times to put these concerns to the Westmead researchers, but they've all declined to speak to us.

51:10

Onscreen text:
"required to communicate research results, whether favourable or unfavourable, in ways that permit scrutiny and contribute to public knowledge and understanding."

In a statement the Sydney Children's Hospitals Network which overseas Westmead  said it's "required to communicate research results, whether favourable or unfavourable, in ways that permit scrutiny and contribute to public knowledge and understanding."

51:21

Onscreen text:
"Specialist Trans and Gender Diverse Health Service for… people under 25 years."

In 2021 the NSW government allocated an annual budget of 1.5 million dollars to open a new gender hub for under 25-years The service is 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. 

51:36

"under development"

New South Wales Health has told Four Corners it's "under development".

51:56

Parents' meeting

LANNEN:  The last item on the agenda is a discussion about Westmead. I know that the clinicians at Westmead certainly were not partners in the research.

52:02

PATRICIA KARVELAS: These Sydney parents, some with kids at the Westmead Children's Gender Service, are worried about the future of their children's care.

52:13

PARENT 2:  The research has brought down an enormous amount of stress. Consequently, we've lost really important people that have been a part of our kids' journey.

52:20

PATRICIA KARVELAS: A paediatrician from the Gender Service left earlier this year distressed over Noah's case and the impact of the controversial research.

52:32

Lannen 100%

LANNEN DONNELLY:  For some staff to be considering to be leaving because they're not finding it to be a supportive environment to do what they know needs to be done for trans youth is really distressing for the families. For the trans youth that desperately need that support what's going to happen to them.

52:41

Ashley working as tradie

PATRICIA KARVELAS: Lannen's son Ashley eventually sought private medical care to have chest surgery and cross sex hormones.

53:01

ASHLEY:  I'm 22, I'm a tradie,

53:14

Ashley 100%

and I want people to know that trans people are here. We exist, and we have existed, and will continue to exist.

53:18

Ashley driving

I'm not really into advocacy. I go to work. I do my job. I go home. That's my life. I'll go out with mates on the weekend, but that's really it. I'm not an activist.

53:31

Ashley 100%

I'm not good with my words. I'm not good with persuading people about why they should change. No, it's better left to people who are better at it.

53:50

Photo. Noah.

PATRICIA KARVELAS: Some people contest whether it should happen at all. They say kids are too young. They say that it's gender activists pushing this stuff onto kids and making

54:07

Lauren 100%

them question their gender. What's your response to that?

LAUREN O'BRIEN: It makes me angry. I've lost my child because there was none of that support. 

54:20

Photo. Noah.

To say that it's gender activists pushing it onto children,

54:34

Lauren 100%

again, why would children choose this if it is so hard? Why would anyone choose something if it's so hard, but if it's not for them being authentic in themselves?

54:42

Brock and family around fire

54:58

BROCK WILLCOCKS: As an adult I see myself to be happy, fully transitioned, healthy and comfortable in my own body. I see myself as a woman and

55:06

Brock 100%

hopefully by that time a lot more people decide to come around and see me as a woman as well.

55:23

Brock and family around fire

55:32

Moon in sky

55:36

Credits [see below]

55:42

Outpoint

56:06