Alex's case: unbalanced evidence and no assurance the treatment will work

The judgement by a single judge of the Family Court approving sexual reassignment for a child aged 13 warrants review as it appears to be based on a lack of adequate medical evidence. There is a need for the state and federal Attorneys General to ensure that the case is assessed by a higher court and to engage a more balanced selection of medical experts.

"Alex" is 13 and suffers from a mental illness that causes her distress and anxiety and social dislocation. Her father, with whom she was close, died traumatically of a stroke. She has no contact with her mother who is remarried. She is cared for by her aunt but is a ward of the state. Major decisions are made for her by a government department.

Evidence was given that Alex feels anger, depression and alienation. She feels sad most of the time and has attempted to self harm. Her psychiatrist found that she had Gender Identity Disorder and some other vulnerabilities and unresolved attachment trauma.

A single judge of the Family Court of Australia has authorised the first stage of a process of hormonal treatment leading to sexual reassignment.

Gender Identity Disorder affects about 1 in 100,000 adolescent girls. This is not just a matter of a girl who wants to be like a boy. But a girl who believes that despite her female biology she is a boy and hates her own femaleness to the extent that it affects her ability to function normally.

The official description of the condition provided by the American Association of Psychiatrists states that a girl with this condition may claim that she has or will grow a penis and may not want to grow breasts or menstruate. She may assert that she will grow up to be a man. Such girls typically reveal marked cross-gender identification in role-play, dreams and fantasies.

The accepted management of this condition is usually psychotherapy aimed at relieving the distress and anxiety by helping her to accept herself as she is, a biological female who identifies as a male. More radically, some clinics have been established that offer gender reassignment which includes hormonal treatment initially followed by surgical treatment to remove female organs and construct male sexual organs.

In adults the medical evidence concerning hormonal and surgical sexual reassignment is equivocal. It appears that those who have the sexual reassignment still suffer similarly high suicide, low unemployment and high levels of social dislocation. Sexual reassignment therapy is not evidence-based medicine. There have been no controlled clinical trials to assess its benefits.

It is thus very disturbing that the judge should have embarked on such a medically untested path, especially in someone so young.

In the judgement there is reference to the evidence of six medical experts. Surprisingly, given the medical controversy and lack of evidence for the procedure generally, all six are completely in agreement as to the medical management of the condition. Given that sexual reassignment is not medically mainstream, the nature of the agreement between the experts raises a question of selection and balance in relation to the choice of experts. The report also indicates close associations between experts, even working in the same place. In an area of controversy it is not unexpected to find experts clubbing together. What is unexpected is that others not so involved appear not to have been asked to provide more balanced evidence.

The first stage of treatment for Alex is to suppress her normal sexual functions by the continuous use of the hormones used in the combined contraceptive pill. The aim is to stop menstruation and ovulation. The hormones have known risks in adults, though the evidence when taken continuously is not so clear, but their effects in a person so young who is still developing are not well researched. The second phase would be to administer hormones to suppress her sex hormones to the level before puberty and to then administer the male hormone testosterone. This would cause irreversible masculization in appearance, and behavioural effects "that would make Alex more assertive/aggressive and have a stronger sexual urge". Later, when Alex is 18, surgery to remove female sex organs and reconstruct male organs may be contemplated.

The case was brought to the Family Court by a government department. The nature of the evidence raises questions about the selection of experts in the construction of the case. The crucial family report in the case was prepared by a probationer psychologist.

This case has the hallmarks of being underdone in the evidence heard and unbalanced in its presentation. It is too important a matter to be left like that. It is a tragic swansong to the distinguished career of the retiring Judge Nicholson.

In the middle of the politics of this controversial therapy and this ill-informed judgement is a young person who has already experienced too much of the hardships that life can bring. That she is now to embark on an experimental path that offers no real evidence of assisting her to overcome her condition and her circumstances compounds the tragedy.