Dozing Down Under
Australia appears oblivious to a dramatic shift overseas favouring more caution in gender medicine
Australia is “asleep at the wheel” as the United Kingdom and other countries back away from “gender-affirming” hormonal and surgical interventions for minors who declare an opposite-sex identity, the New South Wales parliament has been told.
“I am talking about a sea change which has taken place [in the UK, Sweden and Finland while] we as Australians are asleep at the wheel,” said Labor politician Greg Donnelly, who has had long-standing concerns about youth gender clinics.
Last month he put on the parliamentary record the draft treatment plan for England, which would encourage thorough psychotherapy and the cautious “watchful waiting” approach as responses to young people with gender distress. The draft plan warns clinicians that an opposite-sex identity may be only a “transient phase”.
Drugs blocking normal puberty, still used as routine treatment for gender dysphoria in Australia, would be restricted to a formal research setting under the English plan.
This is consistent with serious concerns and uncertainties about puberty blockers raised by the interim report of the eminent paediatrician Dr Hilary Cass, who is leading an independent review of youth gender care.
England’s National Health Service was “further moving away, quite strongly, from the [gender]-affirmative orthodoxy that has been applied hitherto — which is being used, I submit, in NSW,” Mr Donnelly said during a hearing of the health budget estimates parliamentary committee he chairs.
He said young people in NSW were being “very seriously damaged” by gender-affirming hormonal and surgical interventions, while European countries which had been pioneers in youth gender medicine were now more conscious of the risks and unknowns of these poorly evidenced medical interventions.
He cited reports from concerned health professionals of “rapid” dispensing of puberty blocker drugs to children with only two or three appointments at Maple Leaf House, a Newcastle-based gender medicine hub servicing regional NSW.
“This rapid movement [to medicalisation] is completely contrary to what is happening overseas,” Mr Donnelly said.
Last Friday, Florida’s Board of Medicine voted to prohibit future use of hormonal and surgical interventions for minors with the distressful condition of gender dysphoria.
If England goes ahead with its draft plan for gender care, it will join Finland and Sweden in putting a stop to routine use of these interventions to bring about paediatric gender transition.
The world’s largest youth gender service, the London-based Tavistock clinic, is to close next year following advice from Dr Cass.
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Video: British detransitioner Ritchie Herron has launched litigation over medicalised gender change, which he now regrets
What’s behind gender distress?
On October 6, the NSW Liberal Party Minister for Health, Brad Hazzard, responded to Mr Donnelly’s first round of questions by citing advice from his department that minors at Maple Leaf House had comprehensive assessment and diagnosis before any “gender-affirming medical treatment.”
“This occurs in close consultation with the patient, parents and treating medical teams, who must all agree that the treatment is in the best interests of the young person,” the minister said.
Parents internationally have complained that the affirmative treatment model misrepresents parental concern about risky transgender medicalisation as a failure to support the child — and even as neglect requiring intervention by child welfare authorities.
A health practitioner, who spoke to GCN on condition of anonymity, said he knew of one case where Maple Leaf House had “formally facilitated the removal of custody from a parent who disagreed [with medicalisation] or wouldn't engage with [Maple Leaf House].”
This practitioner worried that Maple Leaf House was so focused on gender-affirming medical interventions that patients with non-gender problems — mental illness, autism, trauma or family issues — would not get the attention they needed.
The practitioner said similar concerns had been shared privately among 30-something other health professionals in the Newcastle region, including psychologists, psychiatrists and physicians.
“It is astonishing that Maple Leaf House appears to offer no mental health treatment, nor any ongoing follow-up of patients’ mental health,” he said.
“[Transgender] hormonal treatments should never occur outside the context of whole person management, monitoring and careful follow up of complex co-existing mental health issues.”
It was unclear whether or not the gender medicine hub believed that paediatric transition itself would relieve these other problems.
In a September statement responding to Mr Donnelly’s concerns, the government health district that covers Maple Leaf House said specialised assessment there involved clinicians expert in “psychological medicine, adolescent medicine and endocrinology”.
The statement stresses the need for mental health co-morbidities to receive expert care, but it is unclear whether Maple Leaf House itself provides that care, or does the referrals and follow-up to make sure patients get the help they need elsewhere.
Maple Leaf House, which services large regional areas of NSW, is reportedly facing a challenge in meeting demand, a Sydney medico-legal congress was told earlier this year.
By March this year, the service had seen more than 550 patients — up to the age of 24 — since it was opened in 2021 by Mr Hazzard.
At that point in March, Maple Leaf House was getting 10-12 new referrals a week.
In the period from April 1 to September 30 last year, 59 per cent of 376 patients were aged 17 or younger.
Maple Leaf House is one of two hubs for an expansion of “depathologised” gender-affirming treatment under a new 2022-2027 LGBTIQ+ Health Strategy in NSW, which is Australia’s most populous state.
Comment: England’s draft plan for gender care after closure of the Tavistock clinic is a “seismic” shift away from medicalisation
The other parent
At the 31st Medico-Legal Congress in Sydney in March, a clinician from Maple Leaf House, Liz Nunn, spoke of children “desperate” for puberty blockers having to wait while attempts were made to track down and seek treatment approval from an estranged parent, as required by family law.
She cited a case in which the patient’s birth certificate showed only the mother, and there had been no contact with the father for 12 years.
If there is disagreement between parents, a Family Court application is necessary before a minor can be given puberty blockers, opposite-sex hormones or trans surgery such as mastectomy.
Ms Nunn said delay in medical treatment worsened mental health.
“I really can't see why kids that are 14, 15, 16 can't actually sign for their own treatment,” she told the congress.
“They're allowed to, back at [Newcastle’s] John Hunter Children's Hospital in the paediatric ward, they get to sign for their own operations if their parents aren't there. And a lot of them are way under 16. And it's legal.
“But these kids [at Maple Leaf House] are desperate.
“Puberty blockers are totally reversible. They don't interfere with fertility as some people think, later on — it just suspends it for the time that they're on the blockers.
“So I know I'm passionate about that, but I think it saves a lot of kids' lives if we can just get them onto the blockers without searching for another parent that hasn't given a damn about them for 12 years.”
(If early puberty blockers are followed by opposite-sex hormone drugs — which is the trajectory for the vast majority of patients, according to the limited international data available — then sterilisation is the expected result, as well as sexual dysfunction for male patients.)
Comment: Unpicking misinformation on youth gender clinicsThis week on the show we have a very thorough analysis of & ’s segments on trans kids. I really hope they bother to listen to this because they are wildly ignorant on this issue and don’t seem to realize it.
Out of the loop
A parent separated from his ex-wife and living apart from her and the children told GCN that his teenage daughter, who identifies as male, was referred to Maple Leaf House without “any kind of disclosure or consultation with me as a parent.”
He said his daughter had six months of “gender-support” counselling —apparently to prepare for possible medical intervention — before he knew anything about it.
At the six-month point, the father received an email from the service saying they “valued the input of both parents” and offering appointment times restricted to normal working hours.
A few more months passed before the father had his first meeting with Maple Leaf House clinicians, who briefed him on his daughter’s treatment.
“And they were pretty much already at the point of wanting to start puberty blockers. So, all of this is pretty appalling, because this is my child that they're talking about.”
At that first meeting, the clinicians wanted the father’s approval to start chemical suppression of his daughter’s natural sex hormones, but he told them he would not decide until he had all the information about Maple Leaf House and its treatment options.
“They still insist that puberty blockers are reversible, but there’s just no way — you’re stopping a teenager in their growing years. A teenager grows differently because of puberty blockers, that growth is not reversible, at all.”
The father said the clinicians told him that if he did not approve puberty blockers, they would tell his daughter of his refusal, all her “gender support” would come to an end, and she would be discharged from the service.
“It came across as bad-mouthing me to my daughter — and I would become ‘bad dad’,” the father told GCN.
He felt his initial dealings with Maple Leaf House did not seem like a genuine consultation, and the clinicians appeared to assume he would automatically agree to medical intervention.
ABC News said it was contacted by several parents of patients at Maple Leaf House after reporting of Mr Donnelly’s initial concerns; those parents had mixed views about the treatments on offer.
The local “queer community” reportedly came to the defence of Maple Leaf House, claiming it is “life-saving.”
The promotion of gender medicine as the only fix for an otherwise dramatically high risk of attempted suicide is contentious and not supported by good-quality evidence.
At an October 27 health budget estimates hearing in parliament Mr Donnelly and the Health Minister, Mr Hazzard, clashed over the gender clinic issue.
After Mr Donnelly suggested the minister seemed unaware of February’s internationally significant interim report from Dr Cass, Mr Hazzard said he was aware of both the report — and also of “professional assessments that have raised concerns about it.” He did not give any detail.
Mr Hazzard said he believed Maple Leaf House was doing “an extraordinary job in the most complex of circumstances.”
When Mr Donnelly said the minister was “ignoring tragedy going on in NSW”, Mr Hazzard protested that the budget estimates committee was not the right forum for this debate.
“I’m over it, okay? I will not engage with you on this issue,” the minister said.
A health practitioner, speaking on condition of anonymity to avoid activist harassment, told GCN he was worried that mental health disorders and other non-gender problems of patients — detected during assessment at Maple Leaf House — were going untreated and without proper follow-up.
“Maple Leaf House claims to provide a ‘holistic, multidisciplinary’ place for young people ‘who are gender exploring’,” the practitioner said.
“In practice, it seems to serve as a medical funnel designed primarily for initiating non-evidence-based hormonal treatment of teenagers.
“Other issues relating to trauma, family concerns, neurodiversity and mental health concerns are not actively managed by the clinic.
“The [model of] care being offered even falls short of the self-declared ‘standards’ of affirmative care in Australia and abroad.
[This refers to guidelines issued respectively by the Royal Children’s Hospital (RCH) gender clinic in Melbourne and the World Professional Association for Transgender Health (WPATH).]
“Clinics treating gender concerns as a stand-alone issue are now routinely condemned internationally by clinicians, parents and past patients for their inadequate practices and insufficient care.”
In September, the Hunter New England Local Health District — part of the NSW Health Department — issued an “official statement” saying:
“Young people [at Maple Leaf House] are only ever considered for stage one treatment which is the puberty blockers, once [a comprehensive] assessment has taken place and in close consultation with the patient, parents and treating medical teams. This treatment is reversible.”
England’s National Health Service — responsible for the soon-to-be-closed Tavistock youth gender clinic — and New Zealand’s Ministry of Health have abandoned their past assurances that puberty blockers are fully reversible.
The RCH gender clinic, Australia’s most influential, recently told its patients and families that the effects of these hormone suppression drugs on the brain are unknown.
The NSW Health Department’s September 13 statement may be misread as offering the reassurance that minors only get puberty blockers, not potentially lifelong, irreversible opposite-sex hormones.
The department provides online “HealthPathways” material to brief health professionals about the Newcastle-based gender service.
This password-protected information states that minors can be given not only puberty blockers (from 10 years of age), but also opposite-sex hormone drugs.
The HealthPathways webpage says:
“Hormone therapy to masculinise or feminise the body can begin at age 16 years, or earlier, if the adolescent is competent to [fully understand this intervention], and the treating team and parent support treatment.”
Practitioners are also told that patients under 16 need approval from the NSW Civil & Administrative Tribunal before starting opposite-sex hormones, which can lead to sterilisation.
Medical treatment “reasonably likely” to render a patient under 16 “permanently infertile” may attract a penalty of seven years’ imprisonment under the NSW Children and Young Persons (Care and Protection) Act 1998.
In the past, NSW Health has been at pains to point out that the Children’s Hospital at Westmead in Sydney, unlike its interstate counterparts, prescribes only “reversible” puberty blockers, not irreversible opposite-sex hormones.
However, it is expert concern about puberty blockers in particular that has been on the rise over the last few years.
September’s NSW Health statement also says that Maple Leaf House “strictly operates” under the treatment guidelines of WPATH and RCH.
An NHMRC spokeswoman said: “At the screening stage it was determined that the [RCH] guideline did not include a funding statement, an evidence base for the recommendations or information about conflict of interest, and that it would not meet the portal selection criteria, so a full assessment was not carried out.”
The version of the RCH guideline published as a 2018 peer reviewed paper by the Medical Journal of Australia says: “The scarcity of high quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations.”
Two months ago, WPATH launched its latest guideline with lower minimum ages for treatment — 14 for opposite-sex hormones, 15 for removal of breasts, 17 for testicles — and then issued an abrupt “correction” eliminating all age minimums amid confusion and competing explanations.
The WPATH guideline introduces a new chapter on adolescent care, noting “a sharp increase” in teenagers seeking gender treatment, but claiming that a systematic review was “not possible” because of the sparse medical literature.
The guideline also devotes a fresh chapter to “eunuchs”, saying that castration may be “medically necessary gender-affirming care” for adults. However, this advice is offered for adult patients only.
“Due to the lack of research into the treatment of children who may identify as eunuchs, we refrain from making specific suggestions,” WPATH says.
Note: GCN put questions to Mr Hazzard’s office, his department, the Hunter New England health district, Maple Leaf House, and the chief psychiatrist Dr Murray Wright. GCN does not dispute that gender-affirming clinicians genuinely believe their interventions help vulnerable youth.