Brand new?
Australia is promised a new treatment guideline, not a mere update of the existing contentious document, and detransitioners are to get a say
Make it new
The National Health and Medical Research Council (NHMRC) says it has been asked to develop a new guideline for youth gender dysphoria rather than an update of the low-quality 2018 document from the Royal Children’s Hospital (RCH) Melbourne.
“NHMRC, as an independent statutory agency, has been tasked with developing new independent, evidence-based guidelines. It is not an update of existing guidelines,” a senior NHMRC official, Alan Singh, said in a March 18 email to the group Parents of Adolescents with Gender Distress-Victoria (PAGD Vic), which had expressed concern about the integrity of the project.
“We will be following our best practice processes and procedures to develop new guidelines,” Mr Singh said.1
He said the NHMRC would seek advice from governance experts on recruitment for committees involved in developing the new guideline. “We will be ensuring voices from varied lived experiences are represented, such as those who have discontinued treatment or detransitioned,” he told PAGD Vic.
Talk of the NHMRC assignment as a mere update of the flawed RCH Melbourne guideline—and one driven by the gender medicine lobby—had aroused fears of a political fix to shield the besieged “gender-affirming” treatment model from international pressure for greater caution.
The 2018 document from the RCH gender clinic—the Australian Standards of Care and Treatment Guidelines For Trans and Gender-Diverse Children and Adolescents, to give it its full title—has been pivotal in entrenching in Australia the “gender-affirming” model with its puberty blockers, cross-sex hormones and, in some cases, double mastectomies for minors.
“The [RCH Melbourne] Australian Standards of Care and Treatment Guidelines is accepted as the current gold standard care for Australia and is used as such across the country.”—Dr Michelle Telfer, first author of the guidelines, then director of the RCH Melbourne gender clinic and immediate past president of the Australian Professional Association for Trans Health (AusPATH), parliamentary submission, 9 December 2020
Which is it?
Australia’s federal Health Minister Mark Butler and his deputy, Ged Kearney, have sent mixed messages about the nature of the task assigned to the NHMRC.
In his official written announcement on January 31, Mr Butler said he had asked the NHMRC to “develop new national guidelines” and to undertake “a comprehensive review” of the 2018 RCH Melbourne guideline.2
However, on social media the same day, Ms Kearney said the job was an “update” of the “excellent” RCH guideline as requested by gender medicine lobbyists, the Australian Professional Association for Trans Health (AusPATH) and Transcend, which she said would be consulted “very closely” by the NHMRC.3
In remarks to journalists Mr Butler also mentioned the role of those “gender-affirming” lobbyists and used the newly assigned NHMRC job to try to pressure the state of Queensland to abandon its own independent review of the evidence for puberty blockers and cross-sex hormones.4
During that media conference Mr Butler also appeared to prejudge the evidence question by implying that Queensland’s cautionary pause on new treatment with blockers and hormones was denying young people “access to the best possible comprehensive and appropriate care.”
Queensland’s policy, which was announced only three days before Mr Butler’s dramatic NHMRC intervention, has been opposed by AusPATH and Transcend.
“Children and adolescents with gender dysphoria often experience stigma, bullying, and abuse, resulting in high rates of mental illness, including depression, anxiety, and self-harm. But with supportive, gender-affirming management—as laid out by the Australian guidelines [from RCH Melbourne]—these consequences can be minimised.”—The Lancet, unsigned editorial, 30 June 2018
“The evidence of medium-term benefit from hormonal treatment and puberty blockers is based on weak follow-up studies. The [RCH] guideline does not consider longer-term effects, including the difficult issue of detransition. Patients need high-quality research into the benefits and harms of all psychological, medical, and surgical treatments, as well as so-called wait-and-see strategies.”—Drs Richard Byng, Susan Bewley, Damian Clifford and Margaret McCartney, letter to the editor, The Lancet, 8 December 2018
Dear Minister
On February 1, PAGD Vic wrote to Mr Butler expressing concern about the credibility of the NHMRC project, given Ms Kearney’s comments and the fact that AusPATH and Transcend have acknowledged neither “the poor evidence base for the [RCH Melbourne] guidelines, nor the increasing international discussion regarding the safety and efficacy of the affirmation model.”
Replying on the Minister’s behalf, Mr Singh’s March 18 email said the NHMRC guideline development process would involve “scoping existing international guidance, establishing relevant clinical questions and searching the international literature as per recognised methods of guideline development and standards.”
“As per NHMRC standards for transparency we publish our process and decisions regarding the selection of committee members, what their affiliations and declarations of interest are and whether any conflicts are to be managed.”
Mr Butler’s official announcement made the point that the NHMRC would use the international GRADE system to rate the quality of evidence said to support the treatment recommendations of the new guideline.
This is significant because multiple systematic reviews—independently undertaken since 2019 in jurisdictions as different as Finland, Florida, Sweden, the UK, Germany and Canada—have found that the evidence for the use of puberty blockers and cross-sex hormones with gender-distressed minors is very weak and uncertain.
The RCH Melbourne document—promoted as “Australian standards of care” and adopted as a de facto national treatment guideline—failed to rate the quality of the evidence for its recommendations. Like other gender-affirming guidelines internationally, it was found to be of little rigour in a peer-reviewed evaluation undertaken during the UK Cass review.
AusPATH had endorsed the 2018 treatment guideline from the RCH gender clinic and was to have presided over the first major revision of the document. The clinic has been closely aligned with both AusPATH and Transcend.
Video: The gender medicine correction is more advanced in the UK, although there are plenty of unsettled issues after the historic 2020-24 Cass review, as discussed here by a panel bringing together clinicians and journalists.
“… the main psychiatrists’ body, the Royal Australian and New Zealand College of Psychiatrists, last month quietly abandoned its reliance on those RCH [treatment] standards in its trans health policy. It had done this pending ‘further review’ of the evidence for the standards, RANZCP president John Allan said yesterday.”
“In August, The Australian reported questions about the claimed national status of the RCH standards, as well as international critics saying the document overplayed evidence and lacked caution.”—news report, The Australian, 12 October 2019
Badge not obtained
Meanwhile, it has emerged that back in 2018, the RCH Melbourne gender clinic hoped its then new guideline would earn the stamp of approval from the NHMRC.
RCH contacted the NHMRC in October 2018 “seeking a meeting to discuss what was involved in getting approval for the next revision” of the guidelines, which were first published earlier that year, according to documents obtained under Freedom of Information (FOI) law.5
“We met once and, as I recall, two sticking points were the proposed guidelines had already been published, and were not national guidelines which would make them ineligible for NHMRC approval,” the agency’s Mr Singh said in an internal memo of July 2023.6
“Following the one meeting, we had no further contact.”
This exchange between RCH and the NHMRC has not been reported before.
To win NHMRC approval, a treatment guideline must meet certain requirements.
“NHMRC approval indicates to users that a guideline is of high quality, is based on the best available scientific evidence, and has been developed to rigorous standards. They are recognised in Australia and internationally as representing current knowledge and best health practice,” the NHMRC website says.
In tension with the marketing of the 2018 RCH document as “Australian standards,” all four authors were from the RCH gender clinic. National guidelines normally draw on the expertise of multiple centres.7
Although now badged as Version 1.4 of 2023, the RCH Melbourne guidelines have not had their reference list updated, with the latest studies cited being from 2018. There have been significant changes in the scientific literature since then.
In 2021, The Australian reported that the NHMRC had considered the 2018 RCH guidelines for inclusion in the council’s online portal of Australian Clinical Practice Guidelines but they did not qualify.8
“At the screening stage it was determined that the [RCH] guideline did not include a funding statement, an evidence base for the recommendations9 or information about conflict of interest, and that it would not meet the portal selection criteria, so a full assessment was not carried out,” a spokeswoman for the NHMRC said at the time.
This screening was at the initiative of the NHMRC, not RCH Melbourne. “The guidelines were identified during a routine sweep of new guidelines by NHMRC staff,” the spokeswoman for the agency said.
Selection for the portal, which no longer operates, represented a less strict standard than required for approved status, as the portal was also open to guidelines not approved by the NHMRC.
In 2021, the portal contained 2,800 guidelines.
GCN sought comment from RCH.
The NHMRC project is expected to run for three years, with interim advice on puberty blockers issued in mid-2026. The first phase of the project—which includes planning and appointing the expert committee to oversee development of the guideline—is expected to finish by July.
A spokeswoman for the NHMRC told GCN that Mr Butler’s Department of Health and Aged Care had allocated $2 million for the new guideline project. “The usual method for work undertaken by NHMRC that is funded by the Department is a schedule to a Memorandum of Understanding,” she said.
Ms Kearney chairs the federal Government’s LGBTIQA+ Health and Wellbeing 10-year National Action Plan Expert Advisory Group, which includes representatives of Transcend and others who promote the gender-affirming medicalisation of minors.
This state review is potentially Australia’s first serious review, external to government, of youth gender dysphoria treatment. Previous reviews have been affected by undeclared conflicts of interest, suspected government influence or inadequate terms of reference.
In August 2019, The Australian newspaper asked the NHMRC whether the RCH guidelines were NHMRC-endorsed. The reply was: “No. The guideline developers have not sought, and have not been assessed for, NHMRC approval.” The October 2018 contact did not culminate in a formal request for approval, an NHMRC spokeswoman said on Wednesday.
In 2023, Mr Singh’s recollection was that the approach was made by both RCH Melbourne and its research partner, the Murdoch Children’s Research Institute. In a June 2021 document, however, he referred to an approach from RCH alone. Nothing may turn on this difference.
In 2021, when I was reporting for The Australian newspaper, the NHMRC spokeswoman told me it would “only approve guidelines that are intended to apply nationally; it will not consider for approval guidelines developed for a specific local context or health service.” Under NHMRC standards, the expert committee developing a guideline “must contain representation from the relevant range of clinical professions, as well as end users, and consumers.”
“We would expect that the people on the committee would be leaders in their field, well aware of the body of evidence, and able to contribute to analysing that evidence. Thus, it is theoretically possible for a guideline development expert committee to consist of individuals from one organisation, but it would be unusual for the relevant expertise at the required level to be found in one place [such as the RCH gender clinic],” the spokeswoman said.
Disclosure: I was the author of past coverage for The Australian cited in this post. My October 2019 news report on the psychiatry college disendorsing the RCH guideline, pending a review, was ruled inaccurate by the Australian Press Council. That ruling was obtuse.
Following The Australian’s scrutiny of the RCH guideline, the college had deleted from its LGBTQ mental health policy the recommendation that puberty blockers be prescribed in line with the RCH document. Making an announcement about this would have exposed the college to trans activist pressure and so the change was made on the quiet.
However, after the change was noticed, I sought comment from the college, which confirmed the removal of the endorsement, pending a review of the evidence. With my news report, I put both of these facts on the public record. Reviews have followed and the college has not reinstated its endorsement of the guideline.
It is considered good practice for guideline developers to begin with a systematic review of the evidence base to underpin their treatment advice.
It certainly doesn’t sound like an improvement. I am very suspicious of anything Mark Butler and Ged Kearney do.
On August 16th 2019, then Federal Minister of Health Greg Hunt wrote to the Royal Australasian College of Physicians (RACP) seeking advice on the treatment of gender dysphoria in children and adolescents.
RACP’s response included:
“A national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families through increased media and public attention”.
. . . . The RACP advised against an inquiry.
It is surprising that our peak medical body would resist an inquiry into a medical procedure that almost exclusively involved children who were irreversibly surgically mutilated and permanently sterilised, particularly given that the ‘Affirmative Model of Gender Care’ was/is not evidence based..
Five years have passed since that rebuttal, let’s hope something substantive will come from what is now being considered.