Australia’s most populous state of NSW has begun a dramatic expansion of medicalised gender change for young people despite the government’s own medical experts warning of potential harm and a little-known official report acknowledging the “low quality” of evidence for these life-altering treatments which can sterilise children.
This expansion of “gender-affirming” puberty blockers and cross-sex hormones in the state of NSW is expected to continue whether or not the nominally centre-right government of Premier Dominic Perrottet loses office in tomorrow’s state elections.
Easier, faster access to more transgender medicine appears to have bipartisan support in NSW, while internationally concerns about the safety of the poorly evidenced gender-affirming treatment model are gathering momentum.
In the name of the “LGBTIQ+ community”, trans activism has become a unity ticket between the minority Liberal-National coalition led by Mr Perrottet, known as a staunch Catholic, and the centre-left Labor Party under the opposition leader Chris Minns, another Catholic.
Socially progressive Liberal and Labor members of parliament appear to regard trans rights and youth gender clinics as akin to gay liberation and an unambiguous good that enjoys the full support of the LGBTIQ+ community. The international fracture between mainstream LGB people and the Queer Theory-driven trans agenda has been little reported in Australia.
Video: Alarmed by gender ideology at odds with same-sex attraction, the LGB Alliance launched in the U.K. in 2019, and chapters quickly followed in many countries, including Australia
Pollsters suggest that Sydney independent MP Alex Greenwich, an openly gay man who has a laundry list of LGBTIQ+ legal and health policies, is likely to maintain his outsized political influence in the state of NSW if neither of the two major parties can form a majority in its own right after Saturday’s poll.
Thanks to the close working relationship between Mr Greenwich and Liberal Health Minister Brad Hazzard, the former NSW AIDS council, ACON, is leading a $4.2m project to set up a statewide LGBTIQ+ health centre which will include gender-affirming treatment.
“I’m really proud as the member for Sydney to have secured a great deal of funding for LGBTI communities. Many of the cheques were signed by Brad—so, thank you, Brad!” — MP Alex Greenwich, ACON NSW election event, 16 March 2023
ACON, which now operates as a national trans rights lobby, did not reply when GCN asked if the new health centre would use the fast-track “informed consent” process, with no mental health assessment, for young people seeking medicalised gender change.
In 2020-21, ACON’s TransHub website twice had to correct legal advice favouring easier, earlier access to hormonal interventions for minors.
New in town
Meanwhile, Newcastle’s government-run Maple Leaf House, a gender-affirming clinic opened in 2021, already has a larger number of minors on puberty blocker drugs (95 patients as at 24 September 2022) than the more cautious gender clinic of the public Children’s Hospital at Westmead, Sydney (36 natal males and 20 females). The Westmead service has been operating for a decade.
Asked for basic data under a freedom of information request, the supervising government health district for Maple Leaf House has insisted that it cannot say how many of the clinic’s patients are female, and how many are male. An emphasis on biological sex, rather than self-declared “gender identity”, is often denounced by activists as “transphobic”.
“We got [trans youth health care] out of the hospitalised model [at Newcastle’s John Hunter Hospital], we got a lot more money and a lot better services, and when I went up there [to visit the new Maple Leaf clinic], the young people were so pleased to be in that different environment” — Health Minister Brad Hazzard, ACON NSW election event, 16 March 2023
Last year in the NSW parliament, Labor MP Greg Donnelly said Australia was “asleep at the wheel” on the risks of gender-affirming medicalisation.
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, which operates as a gender medicine hub servicing regional NSW.
“This rapid movement [to medicalisation] is completely contrary to what is happening overseas,” said Mr Donnelly, who has been raising concerns since 2016 about the runaway expansion of youth gender clinics.
In response to this scrutiny, the NSW Health district responsible for Maple Leaf House issued a statement last September defending puberty blockers as a “reversible”, carefully considered treatment.
The health district said that Maple Leaf House “strictly operates” under treatment guidelines from the World Professional Association for Transgender Health (WPATH) and the Royal Children’s Hospital Melbourne (RCH).
WPATH claims there are too few studies to carry out a gold-standard systematic review of treatment outcomes for adolescents given gender-affirming treatment, while RCH has insisted there were too few “high-quality” studies to grade the level of evidence for the treatment recommendations in its guideline.
The trustworthiness of both documents has been questioned by a pioneer of the evidence-based movement in medicine, Professor Gordon Guyatt of Canada’s McMaster University.
In its September 2022 statement, the Hunter New England Local Health District also claimed that an independent evidence check, conducted by the Sydney-based Sax Institute, had “found strong evidence for a gender-affirming approach to health care.”
In fact, the 2020 report of this little-known evidence check brokered by Sax—a report that appears to be no longer publicly available—concluded that the overall rating of the available evidence for medicalised gender change with minors was “low quality.”
“Robust evidence of the benefits and harms of medical and psychosocial treatment for [transgender and gender-diverse] children and adolescents is lacking, [partly] due to the emerging nature of this field,” the Sax report said.
It said the empirical evidence for the claimed psychological benefits of puberty blockers was “weak” and there was only “limited evidence” of improved psychological outcomes for minors on cross-sex hormones. (The report did find “strong evidence” that hormone suppression drugs, known as GnRHa, have the physical effect of suppressing puberty, but this is not a key issue in the dispute over claims for gender-affirming treatment.)
Notwithstanding the weak evidence, the Sax report claimed that puberty blocking is “reversible and allows the young person to explore their gender identity before embarking on irreversible, or partially irreversible, treatment.” These claims have been undermined by international data showing that the vast majority of children who start on blockers proceed to cross-sex hormones.
The Sax Institute-badged report, authored by six academics with links to the University of Melbourne, stated that it was commissioned by NSW Health to inform policy decisions about the statewide gender services now being rolled out.
There is no mention of the Sax report in the Perrottet government’s heavily promoted $12m LGBTIQ+ Health Strategy 2022–2027, launched last March by Minister Hazzard, who has said it was “probably one of my proudest moments.”
“When you’re taking advice from the experts in health [and] from the researchers and the non-government organisations [such as ACON], it’s pretty hard to actually do something which is outside the realms of commonsense and decency” — Health Minister Brad Hazzard, ACON NSW election event, 16 March 2023
The new NSW health strategy charts an expansion of gender-affirming treatment, including $3.4m annually for NSW Health’s Specialist Trans and Gender Diverse Health Service “to support trans youth and adults”; the strategy identifies young people aged 12-24 as a “priority group”.
In the name of “depathologisation”, the health strategy discourages the idea that these invasive medical interventions should require a psychiatric diagnosis of gender dysphoria, a condition marked by distress and a feeling of conflict between the body and an inner “gender identity”. It is unusual to prescribe medicine without a diagnosis.
“The pathway of care should focus on depathologising and reducing barriers to accessing gender-affirming treatments and care. [It] should centre on the expertise, informed consent, rights and lived experience of transgender and gender diverse adults, adolescents and children,” the health strategy says.
“I want to acknowledge the excellent work of the [government’s LGBTIQ+] health strategy” — Opposition Labor front bencher Penny Sharpe, ACON NSW election event, 16 March 2023
Since 2020, systematic reviews of the medical literature carried out in Finland, Sweden, the United Kingdom and the state of Florida have all concluded that the evidence base relied on by gender-affirming clinics is weak and uncertain.
These jurisdictions—including, most recently, Norway, which has declared puberty blockers to be “experimental”—have imposed or recommended tight restrictions on the availability of gender-affirming medical treatments for minors.
Internationally significant 2021-23 research from the government’s own Children’s Hospital at Westmead has raised a series of concerns about gender-affirming pressure to medicalise the complex problems of young people and their families.
This open-access research suggests that a medicalised fixation on gender identity may lead to therapeutic neglect of mental health and other issues affecting these patients, including the effects of “adverse childhood experiences” such as family conflict, exposure to domestic violence, parents with mental illness, loss of important figures through separation, and bullying.
But this body of work by the Westmead researchers appears to have been ignored or dismissed by NSW Health, amid bipartisan political support for the dogmatic gender-affirming treatment model and the upbeat LGBTIQ+ Health Strategy.
“I’m a trans man. As a part of my transition, I’ve had a hysterectomy, which has been great for my physical and mental health. But on the day when I went to the hospital for the procedure, the nurse at the intake called me up and asked what I was there for, and when I said ‘a hysterectomy’ she laughed at me and said I was mistaken” — Trans testimony from the “evidence summary” of the NSW LGBTIQ+ Health Strategy
In their latest journal article published last month, Westmead’s expert researchers of youth gender dysphoria warn of treatment regret and “potential harm” if the government’s new LGBTIQ+ health strategy leads to a “loosening up” of traditional, holistic psychiatric assessment of young people before they are put on a potentially lifelong medical path for gender change.
The Westmead researchers led by child and adolescent psychiatrist Dr Kasia Kozlowska emphasise the “many unknowns” of puberty blockers, and the fact that the evidence base for medicalised gender change is “sparse, inconsistent, and low [quality] in terms of evidence-based gradings—especially with regard to children and adolescents.”
They note that the health strategy’s “summary of evidence” document—the work of Urbis, a Sydney planning and policy business—ignores “the voices, experiences, and needs of individuals who desisted [those who cease to identify as trans] or detransitioned [those who stop taking trans drugs].”
They point out that some detransitioners “have reported that, in hindsight, because of their age or mental health concerns, they were not fit to give consent at the time that it was required.
“Some raise regrets about making decisions about their sexuality before that sexuality—and their understanding of that sexuality—was explored and clarified.
“[And] some think—in retrospect—that they were misguided in focusing exclusively on their gender dysphoria: that they should also have considered and addressed some of the concurrent adverse childhood experiences and issues pertaining to peer relationships and emerging sexuality that were contributing to their subjective distress and loss of wellbeing.”
The evidence summary for the NSW health strategy skips the scientific literature on youth gender dysphoria. The studies cited are mostly advocacy research with weak designs and the document appears to reflect an identity politics-driven consultation of LGBTIQ+ lobbies, rather than critical inquiry.
The Westmead researchers, who also have University of Sydney appointments, suggest that the NSW health strategy is moving in the opposite, “non-conservative direction” when compared with the treatment policy corrections in Finland, Sweden and England’s Cass review of youth gender dysphoria care.
The research work at Westmead has been noted by the study protocol for the Cass review’s qualitative research project, as well as by the British psychoanalyst Dr Marcus Evans, a significant figure in helping to expose the failings of the London-based Tavistock gender clinic.
“Barriers to access include the limited number of services in NSW, the high costs of some treatment options such as puberty blockers and surgeries, and the requirement for a diagnosis of ‘gender dysphoria’ by a psychiatrist to access hormone replacement therapy [cross-sex hormones] — Evidence summary of the NSW LGBTIQ+ Health Strategy
The NSW government’s health strategy documents give no hint of the intensifying international concern about the risks of the gender-affirming treatment model, nor key debate topics such as the unexplained flip in patient profile from mostly male early-onset gender dysphoria to chiefly female adolescent-onset dysphoria.
The health strategy does not mention more cautious policy documents on the approach to youth gender dysphoria issued by the Royal Australian and New Zealand College of Psychiatrists (2021) and the National Association of Practising Psychiatrists (2020).
Meanwhile, NSW appears likely to enact Victoria-style legislation making it a criminal offence to engage in “conversion therapy” aimed at changing someone’s sexual orientation or gender identity. Independent MP Greenwich has extracted promises from both Mr Perrottet and Mr Minns that they will support his draft ban on conversion therapy.
Some mental health professionals fear that young trans-identifying people will be denied the benefits of entirely ethical psychotherapy, because if this exploration leads to clients giving up their trans or non-binary identity and becoming reconciled with their sex, it might be misconstrued as conversion therapy.
The Greenwich law would also strengthen the hand of the Australian Professional Association for Trans Health (AusPATH), a hybrid clinical/activist body prone to attack therapeutic alternatives to the gender-affirming model as conversion therapy.
In a recent report as AusPATH president, Dr Clara Tuck Meng Soo described the latest study from Westmead’s gender dysphoria researchers as “another damaging paper [containing] outrageous claims.” She did not give any detail.
“Hopefully, the passage of laws banning sexuality and gender-identity conversion in NSW championed by Alex Greenwich will clip their wings,” she wrote.
The February 2023 Westmead study that she objects to tracked 79 young people seen at the gender clinic and reported that their choices and the passage of time did not automatically lead to a single outcome of trans medicalisation.
Of the 68 patients with a formal diagnosis of gender dysphoria, 9.1 per cent did not persist in their self-declared trans identity.
GCN phoned Dr Tuck Meng Soo to ask if she was claiming that the Westmead research could constitute an offence under the Greenwich bill to ban conversion therapy, but she said, “I’m not interested in discussing this with you”, and hung up.
Earlier this month, she announced her immediate resignation as AusPATH president, citing the distraction of “things happening in both my personal and professional life”. She did not reply to emailed questions.
Note: GCN sought comment from NSW Health, Health Minister Brad Hazzard, Alex Greenwich, ACON, the Sax Institute, Urbis and Dr Kozlowska. It is not disputed that those who promote gender-affirming treatment believe it benefits vulnerable young people.
The Melbourne Royal Children’s Hospital website states, in relation to the use of puberty blockers (GnRH) in young people:
‘They are reversible in their effects, should an adolescent wish to stop taking them at any time their biological puberty will resume’.
The British National Health Service (NHS) has withdrawn the claim that puberty blockers are considered to be fully reversible and replaced with the statement that “little is known about the long-term side effects particularly as it relates to the development of the teenage brain and children’s bones. The psychological effects are also unknown”.
The U.S. Food and Drug Administration (FDA) has added a warning about the possible risk of developing pseudotumor cerebri (idiopathic intracranial hypertension) to the labelling for gonadotropin- releasing hormone (GnRH)
Interesting to note that RCH continues to market the belief that puberty blockers are 'reversible in their effect' !
I cant help wondering what other drugs and treatments will suffer from funding cuts as the funding for gender drugs and affirmation increases.