Morgan Carpenter

I had a friend, a policy-maker and leader, ask me this morning about whether or not children with innate variations of sex characteristics (IVSCs/intersex variations/DSDs) in Queensland can still access HRT or puberty blockers if needed. I’m sharing my answer here, as the issues I raise are not well understood, and I see comments about the situation in Queensland that I find poorly evidenced or speculative.

First off, it’s my view that people should be supported to make their own decisions about their own bodies and identities to the maximum extent possible. Urgent or emergency treatment aside, this means access to support, and access to medical treatment when people have age and agency to freely develop and express their own views about how they are treated.

Like other jurisdictions in Australia, we also lack clear and adequate information about practices across the state. Probably no institution has a good grasp of these data because they aren’t collected in reliable, consistent ways. Even so, we have anecdotal reports from parents and individuals, and evidence from occasional clinical publications, legal cases and government reports. What we know about how Queensland treats children with IVSCs is troubling. And all of this is triggering, but I think it’s important for policymakers and advocates to know.

So, infants and children with IVSCs are not treated by gender clinics, unless they also happen to be transgender, and a case I’m going to refer to in a moment gives an indication of how those children are treated. Most people with IVSCs are cisgender women and men, girls and boys, so when people talk about cisgender people still being able to access hormones and puberty blockers, many of those kids have IVSCs.

In a 2019 presentation by clinicians in a paediatric and adolescent gynaecology service (Adikari et al. 2019), we can see that children are routinely subjected to medical interventions, and this is still seen as clinically appropriate. Multidisciplinary teams may be involved, in the few instances where treatment proposals fit what clinicians consider an ethical dilemma (this does not appear to correlate with what community organisations and human rights institutions consider to be ethical concerns).

Looking at the data shared by the Queensland gynaecology service, all children presenting with so-called “ambiguous genitalia” have had feminising surgery and sterilisations, which has to be followed by hormone replacement therapy. These interventions appear to commence close to the time that the children are diagnosed. Selected examples:

“Gonadectomy and feminizing genitoplasty 1 year age. Vaginal dilatation”
“Gonadectomy and genitoplasy as infant. Pubertal induction and HRT. Vaginal Dilatation.”
“Gonadectomy and reconstructive surgery as infant. Pubertal induction and HRT. Vaginal dilatation.”
“Gonadectomy and surgical creation neovagina as child. Pubertal induction and HRT. Vaginal dilatators.”
“Gonadectomy and surgical creation neovagina in adolescence. Pubertal induction and HRT. Vaginal dilators.” … (Adikari et al. 2019)

When non-urgent interventions such as genitplasties, other feminising (and masculining) interventions, and many gonadectomies take place before individuals can express their values and preferences, they are human rights violations (Australian Human Rights Commission 2021).

There’s another issue that arises out of these preemptive early interventions: it’s that early gonadectomies in children with IVSCs and functioning gonads mean that puberty blockers are irrelevant. Puberty blockers could have been relevant if children retained their gonads, while they were supported to know and express their own preferences and values. But they are not an option now because these children no longer have gonads that produce hormones.

We also have clear evidence from a 2017 legal case in the Family Court. In this case, we can see how an intersex and trans kid always identified as female, but was put on testosterone to kick start puberty – the judge (Tree J.) said that it would have seemed “fanciful” for a judge to have given court authorisation for the testosterone.

When the girl in this case realised what testosterone was doing to her, she became non-compliant. This is unsurprising – she wasn’t given a choice, she had no agency, nor even accurate information on what was being done to her. It’s plausible that, under the current limitations in Queensland, youths in this situation might be offered only the hormone in line with sex observed at birth, and not other options.

So, children with IVSCs can still “access hormones and puberty blockers”, but do children with IVSCs have any agency about early clinical treatment? The answer to that appears to be no, or it appears to be very limited.

There’s another issue here. I recently had a journalist from SBS reach out to me, convinced that people with IVSCs are gender diverse. Some people with IVSCs are, but most aren’t. But the consequence of this framing is that all the distinct issues I raise in this post are incomprehensible to her, and made incomprehensible in reporting that doesn’t understand the differences between our populations.

Is there any evidence of change since publication of the sources I mention? There’s no evidence of change. In fact, there is evidence of unsubstantiated claims of change to clinical practice dating back to 2012, and these claims are falsified by the evidence published since (Carpenter 2024).

While InterAction has raised issues relating to medical interventions and psychosocial support repeatedly with the Queensland government (in previous terms of office), that government has repeatedly sought to reframe our concerns as about gender identity issues.

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These are the sources I mention in this post:

Adikari, T, B O’Brien, T Bagchi, and RMN Kimble. 2019. ‘Presentations and Outcomes of Patients with Disorders of Sexual Development (DSD) in a Tertiary Paediatric and Adolescent Gynaecology (PAG) Service’. Presented at the RANZCOG Annual Scientific Meeting 2019, Melbourne. https://ranzcogasm.com.au/wp-content/uploads/2019/10/243.pdf

Australian Human Rights Commission. 2021. Ensuring Health and Bodily Integrity: Towards a Human Rights Approach for People Born with Variations in Sex Characteristics. Sydney, Australia: Australian Human Rights Commission. https://humanrights.gov.au/intersex-report-2021.

Carpenter, Morgan. 2024. ‘Fixing Bodies and Shaping Narratives: Epistemic Injustice and the Responses of Medicine and Bioethics to Intersex Human Rights Demands’. Clinical Ethics 19 (1): 3–17. https://doi.org/10.1177/14777509231180412

Family Court of Australia. 2017. Re: Kaitlin. FamCA 83. http://www.austlii.edu.au/au/cases/cth/FamCA/2017/83.html