Special issue on gender and health: listening to the voices of patients

In their 2024 work Who's afraid of gender?, Judith Butler1 charts the rise of an international so-called anti-gender ideology movement, in which the concept of gender operates as "phantasm". That is, a site where disparate contemporary fears — be they around the future of work, family life, or other aspects of the world — gather and become weaponised for political ends. This weaponisation of gender is having far-reaching impacts across the globe, including on public health policy and the practice of medicine.2 In one of the most striking recent examples, the United States under the Trump Administration is undertaking extraordinary attacks on sexual and reproductive health and rights, in part under the guise of "defending women from gender ideology extremism and restoring biological truth".3, 4 Australia too is seeing its share of backlash against gender equity in the sphere of health, including use of anti-gender ideology discourse to mobilise opposition to health care access for transgender (trans) people.5, 6 It is against this backdrop that the Medical Journal of Australia dedicates a special issue to the topic of gender and health. In doing so, we do not seek to prescribe specific definitions of "sex" or "gender" for adoption across health and medicine. These are often contested terms subject to evolving and varied scholarship, including growing recognition that they might defy efforts to map them neatly onto a "biological" and "cultural" binary.1 In line with the Sex and Gender Equity in Research (SAGER) guidelines,7 which the journal endorses, these terms should be clearly defined by authors and used with precision and consistency throughout their work. The goal of this special issue is to provide a platform for research and analysis that engage with what gender means for Australian health care in a manner informed by evidence, scientific rigour, a quest for equity and justice and, fundamentally, respect for the rights, dignity and perspectives of affected populations. Its curation was premised on an understanding of gender as "the structure of social relations and practices that are organised in relation to reproductive bodies".8 The articles in this issue cover diverse ground. Harsha Ananthram and colleagues9 seek to unpack the term "obstetric violence" in the context of findings from recent inquiries into birth trauma in Australia and the United Kingdom. In Australia, practitioners who refuse to participate in abortion care should refer their patients onwards to a willing provider. Shelly Makeleff and colleagues10 argue that not enough attention has been given to how these referrals are carried out and propose strategies to promote person-centred abortion referrals. The potential to improve the care of people with anxiety disorders through sex- and gender-responsive management approaches is explored by Bronwyn Graham,11 who notes that sex and gender are relatively ignored in anxiety disorder research, medical curricula, and clinical guidelines. Findings from a cohort study done in New South Wales show that although the gender gap in the treatment and outcomes of ST-elevation myocardial infarction (STEMI) has narrowed in recent years, the high disparity between male and female patients with STEMI is unlikely to close in the next decade.12 And a pharmacoepidemiology study from Kailash Thapaliya and colleagues13 highlights gaps in evidence and guidance for the prescribing of glucagon-like peptide-1 (GLP-1) receptor agonists for women of reproductive age. Three articles in this special issue specifically address trans health. First, Kade Booth and colleagues14 discuss the disparities faced by trans and gender diverse people in accessing cervical cancer screening and vaccination against human papillomavirus, and propose several potential solutions. Second, a perspective article by Julia Moore and colleagues15 engages with the Independent review of gender identity services for children and young people, or Cass Review, commissioned by England's National Health Service and published in 2024.16 The authors critique the findings of the Review on several grounds, including a lack of representation of the views of trans adolescents, and ultimately conclude the review represents a "failure of evidence-based medicine". "Good medicine" they contend "is guided by the values of the patient, not those of a clinician, politician or commentator. A patient's goal of achieving optimal quality of life as a trans person requires respect". This point is directly addressed by the third article on trans health in this issue, from Jayne McFadyen and colleagues.17 In 1987, the MJA published the report of a case series of eight gender diverse children.18 To correct what was termed their "cross-gender behaviour", these children had been administered "therapy" as inpatients for between six and 28 weeks. The report concluded that "the treatment of cross-gender behaviour by means of inpatient therapy seems effective". It continues to be cited in contemporary debates about young people's access to gender affirming care and about so-called conversion therapy. Decades later, the MJA was approached by Jayne and her co-authors with a request to consider an article in response to this work: Jayne is a trans woman who reasonably believes, on the basis of evidence available to her, that she was one of the children described in the 1987 article. The author team had undertaken an analysis of archived mental health records, published details from the 1987 case series, and Jayne's autoethnographic account of her treatment, and concluded that the inpatient treatment Jayne had received constituted a form of conversion therapy aimed at "extinguishing childhood behaviours deemed to be socially undesirable". Despite the claim from the 1987 report that this treatment appeared effective, for Jayne the attempt to change or suppress her gender identity "served to delay self-acceptance for two decades and caused long term harm". As journal editors, at the forefront of our minds every time we decide to publish an article are questions about the potential harms that could result from our decision. We must ask ourselves: are we confident the findings reported are legitimate, produced ethically, analysed appropriately, and reported in a balanced and transparent manner? Could our decisions inadvertently contribute to undermining public trust in science or to supporting ineffective or even harmful medical practices? To mitigate these concerns, we take expert advice from peer reviewers and consider it carefully in the context of what has been previously published. We have no reason to believe that those involved in the 1987 MJA article had anything but the best intentions, given the knowledge and dominant gender norms of the day. But what is apparent is that the practices of medicine and scholarly publishing at the time did not place sufficient value on the views, experiences and preferences of the young people whose wellbeing was at stake. Genuine evidence-based medicine requires epistemic pluralism, including understanding the value of patient voices. This is where the work of Jayne and her colleagues becomes particularly important. At the MJA, we appreciate the power imbalances at play here. These exist between medical experts with professional standing, a scholarly journal with an established national reputation, and a patient, who at the time the "inpatient treatment" was administered was a child. In this context, we are immensely grateful that Jayne and her co-authors chose to entrust their work to the MJA for consideration. As editors, we are also grateful for the opportunity this experience has afforded us to reflect and act on what it means to demonstrate institutional accountability for past decisions. What constitutes the best care for trans young people should of course be up for debate, as is the case for all areas of medicine. It is the role of medical journals to ensure that this debate is rooted in humane values and is driven by evidence — of which the views of patients are an essential part.