Butler did it

Australia's health minister has relied on a discredited report to kill off talk of a gender clinic inquiry

Photo by Bacila Vlad on Unsplash

Australia’s Health Minister Mark Butler has a track record of dismissing calls for an inquiry into gender clinics by relying on the opinion of a medical association which suppressed expert concerns about hormonal treatment of minors.

Endocrinologists, the key experts for the life-altering hormonal interventions used by gender clinics, had cited a lack of evidence for the claim that puberty blockers are reversible, but this warning never reached the federal government.

The release this month of England’s 388-page Cass report—which says “there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development”—has led to renewed calls for an inquiry in Australia.

Mr Butler has recognised the Cass report as “significant”, but like Australia’s gender clinic lobby, he has played down its local relevance by citing differences in pathways to treatment. (The evidence base and the treatment—puberty blockers followed by “gender-affirming” cross-sex hormones—are the same internationally.)

Last week, UK Health Secretary Victoria Atkins said doctors could be struck off if they prescribe puberty blockers in defiance of the Cass policy confirming the restriction of these experimental drugs to clinical trials overseen by England’s National Health Service (NHS). Ms Atkins also foreshadowed possible legislation to stop puberty blocker supply by private clinics and online dispensaries registered abroad.

The rogue online clinic GenderGP, which uses the gender dysphoria treatment guideline issued by the Royal Children’s Hospital Melbourne (RCH), has rejected the Cass report, claiming that “children and young people will suffer and die¹ if these recommendations [in the Cass report] are implemented.”

By contrast, the editor-in-chief of the British Medical Journal, Kamran Abbasi, has described as “alarming” Dr Cass’s conclusion that gender medicine was “built on shaky foundations.” Dr Abbasi said the Cass advice and the decision to restrict blockers to the research setting put England “firmly in line with emerging practice internationally, such as in Scandinavia.”

Video: UK Health Secretary Victoria Atkins on the culture of secrecy, activism and lack of evidence surrounding gender medicine

The warning not heard

Last July, the month after England’s NHS announced puberty blockers were so poorly evidenced that they would no longer be given as routine treatment, Australia’s Labor Party Health Minister Mark Butler dismissed a petition seeking an inquiry into “medical best practice in treating gender confusion in children and young adults.”

The petition might have alerted him to a development little reported by most local media outlets—Europe’s trend away from the “gender-affirming” medicalisation practised in Australia and towards a holistic, mainstream mental health response to gender distress.

“Countries such as Sweden, Finland, France and [the] UK are reviewing, re-evaluating, stopping, or advising caution on the treatment of gender dysphoria in children and adolescents,” the petition says. “Young Australians are emerging who regret treatments which have left them scarred and infertile for the remainder of their lives.”

Mr Butler’s response to the 28,265 petitioners cited a 2020 letter from the Royal Australasian College of Physicians (RACP) warning his portfolio predecessor Greg Hunt against an inquiry into gender clinics. (In 2019, Mr Hunt had asked the RACP for advice on gender dysphoria treatment after The Australian newspaper reported concerns.)

On 31 July 2023, Mr Butler’s letter dismissing the petition said: “The RACP advice was informed by consultation with relevant clinical experts and noted a national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families.”

In fact, earlier that month, The Australian revealed that during consultation, the RACP had received a confidential letter from the Medical Affairs Committee of the Endocrine Society of Australia expressing serious reservations² about the hormonal treatment of dysphoric minors and the quality of the 2018 RCH treatment guideline.

The RACP did not pass on these concerns in its March 2020 letter of advice to Mr Hunt. It emerged that the RACP had previously lobbied³ for easier, less expensive access for minors to the puberty blockers⁴ and cross-sex hormones⁵ it was supposed to evaluate for the health minister.

Its four-page advice to Mr Hunt did not mention these treatments⁶ and implied a vague endorsement of the RCH guideline, while conceding the evidence base was “limited.”

The RACP advice⁷ has been repeatedly relied on by senior officials in Mr Butler’s Department of Health when briefing him on how to handle persistent calls for an inquiry.

Video: Sky News’s Peta Credlin talks to whistleblower psychiatrist Jillian Spencer on the Cass report’s implications for Australia

“I hear your concerns, but…”

In October 2022—seven months after the interim Cass report raised serious concerns about puberty blockers—officials sent Mr Butler “talking points” in an emailed brief with the subject line, “Urgent inquiry into the treatment of gender-confused children in Australia”.

This time the request for an inquiry came from the office of former Labor leader Bill Shorten, acting on behalf of a person or group whose name was redacted in documents released under Freedom of Information law. It may have been one of his Melbourne constituents; Mr Shorten’s office did not reply to a request for clarification.

The “standard word response” from Mr Butler’s department to Mr Shorten’s office says, “I hear your concerns,” but goes on to cite the RACP advice and its unsupported claim that an inquiry would do “harm” to young, transgender-identified patients and their families through “increased media and public attention.”

The two-page brief for the minister’s reply attributes “increased concern about care in Australia” to the foreshadowed closure of England’s Tavistock gender clinic.

It notes Dr Cass’s interim report from February 2022 and her July 2022 letter to the NHS, but gives a perfunctory and misleading account of the changes under discussion as if they are mostly a matter of restructuring and expansion to cater to unmet demand. Their direct relevance to Australia is not made clear.

The brief fails to mention—

Dr Cass’s reliance on systematic reviews—undertaken independently in 2020—showing the very weak evidence base for the same hormonal interventions used as routine treatment for minors in Australia;

her concern that the effect of puberty blockers on the brain is unknown;

her highlighting the possibility that blockers may lock-in gender distress;

her worry that the profile of patients has radically changed, meaning there is no data guiding their treatment;

her warning that the gender fixation of the affirmative treatment model (also used in Australia) may “overshadow” underlying non-gender conditions in need of priority treatment.

Dr Cass’s interim report and her July 2022 letter to the NHS clearly articulate⁸ the risks and shortcomings of the gender-affirming treatment model and its hormonal interventions.

Blockers and the brain

On 30 November 2022, the day after the One Nation Party leader Pauline Hanson foreshadowed a motion for a Senate inquiry into puberty blockers and the rise of rapid-onset gender dysphoria, Australia’s senior health officials and Mr Butler’s parliamentary adviser workshopped a response in emails marked “URGENT”.

One official from the department’s “Health Equity Branch” recommended previous “talking points” and added, “[I] also suggest relying heavily on the RACP 2020 advice if possible.”

The resulting three-page brief cites the RACP advice under the heading, “Possible harm caused to trans kids through public inquiries.”

The brief says that the causes of the increase in gender dysphoria internationally are unknown.

It asserts that puberty suppression “is reversible in its effects,” citing the 2018 RCH guideline and current standards of care issued by the World Professional Association for Transgender Health (WPATH) and the Endocrine Society.

However, the 2018 RCH treatment guideline used by children’s hospital gender clinics in Australia says nothing about puberty blockers and the brain⁹. The guideline has not been updated to reflect recent research¹⁰, including data showing that the vast majority of children begun on blockers go on to irreversible cross-sex hormones supposed to be taken lifelong.

In the first half of 2022, however, the RCH gender clinic did inform patients and parents via a newsletter that the effect of blockers on the still developing adolescent brain was unknown, and foreshadowed recruitment of subjects for research into this question. The hospital has not offered any public explanation for the contradiction between this admission and its treatment guideline.

The current, 8th version of WPATH’s standards claims puberty blockers are reversible, while at the same time recognising the need to research their cognitive effects: “Puberty is a time of significant brain and cognitive development. The potential neuro-developmental impact of extended pubertal suppression in gender-diverse youth has been specifically identified as an area in need of continued study.”

The Endocrine Society’s 2017 guideline also asserts that blockers are reversible, but admits the need for research into “the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development)…”

The Australian health officials’ brief on how to counter Senator Hanson’s call for an inquiry makes the dubious claim that low bone density is “the main concern” with puberty blockers. It also states, “Research shows that puberty suppression typically relieves distress for young people experiencing gender dysphoria”, when there is no good quality evidence for this claim, according to systematic reviews.

Inside the Tent

Last September, Mr Butler was sent another departmental brief, following his meeting between with Ms Nicky Bath from the gender medicine lobby group LGBTIQ+ Health Australia. Under the heading “Sensitivities”, this brief frames media debate about gender clinics as a problem to be fixed. It says—

“There is regular media expressing differing views on gender-affirmation treatment. This media has often caused significant distress within the transgender community and has been raised at the LGBTIQA+ Expert Advisory Group for the development of the 10-year Action Plan, chaired by Assistant Minister [Ged] Kearney.”

That advisory group includes researcher Ashleigh Lin, president of the gender-affirming lobby the Australian Professional Association for Trans Health; Mr Jeremy Wiggins of the trans activist group Transcend Australia; and two former gay rights lobbies, Thorne Harbour Health and ACON, which have moved into trans activism and gender medicine. (Professor Lin has claimed that the European turn to caution reflects the influence of an “anti-child and -adolescent affirming lobby”; she did not reply when asked for evidence of this.)

1. The Cass report debunks the “transition or suicide” narrative of gender clinicians. The report says: “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found did not support this conclusion.”

2. In its confidential letter, the Medical Affairs Committee of Australia’s endocrine society opposed any endorsement of the 2018 RCH treatment guideline, which has been promoted as “Australian standards of care”. The committee warned the RACP that “the RCH document largely reflects the authors’ opinion because, as the authors themselves state, ‘the [scarcity of high-quality] published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations’.” This claim that the evidence could not be rated led Professor Gordon Guyatt, a pioneer of evidence-based medicine, to declare the RCH guideline untrustworthy.

3. Four days after Mr Hunt’s 2019 letter seeking advice, the RACP issued a statement endorsing the 2018 treatment guideline issued by RCH. This implied the guideline would be a benchmark for the review requested by Mr Hunt, rather than a contentious document requiring critical analysis. And this hasty prejudgment also raised the possibility that the RACP had a conflict of interest; sure enough, such conflicts were easily discovered. The RACP refused to comment on these conflicts.

4. In February 2015, the RACP lobbied for public funding of puberty blockers, protesting that the cost of roughly $5,000 a year “prevents care from being affordable in general practice and community settings.”

5. In May 2015, the RACP issued a media release supporting paediatrician Michelle Telfer, director of the RCH gender clinic, in her hospital’s campaign to reduce judicial oversight of treatment decisions starting minors on irreversible cross-sex hormones.

6. In 2016, the RACP, in concert with the college of psychiatry and a trans activist lobby, asked the NSW government for $8m over four years to set up an RCH-influenced network of gender clinics with The Children’s Hospital at Westmead in Sydney as the centre. The proposal cited “close consultation” with Dr Telfer of the RCH gender clinic.

7. In July last year, RACP president Jacqueline Small played down the significance of the March 2020 advice to Mr Hunt, noting that the advice “did not comment on specific clinical issues such as the use of puberty blockers and other treatments.” In correspondence, Dr Small said the RACP was “not intending to develop clinical guidelines or position statements on the treatment of gender dysphoria.”

8. In April 2022, reflecting the international relevance of the Cass interim report, the BMJ published an editorial written by Australian authors Dr Telfer, director of the RCH gender clinic; the clinic’s head of research, Dr Ken Pang; and trans activist Mr Jeremy Wiggins of Transcend Australia. Their argument was that gender clinics should carry on with puberty blockers and cross-sex hormones for minors rather than wait for long-term safety data. The editorial said: “In what was likely a disappointment to many, the interim report [from Dr Cass] did not provide definitive advice on the use of puberty blockers and feminising or masculinising hormones… In particular, the report expresses the need for more long-term data to assuage safety concerns regarding these hormonal interventions. Although additional data in this area are undoubtedly needed, the decision to delay recommendations pending more information on potential unknown side effects is problematic…” 

9. In a recent paper, Professor Sallie Baxendale, who holds a chair in clinical neuropsychology at University College London, says: “Whilst there is some evidence that indicates pubertal suppression may impact cognitive function [such as intelligence measured by IQ], there is no evidence to date to support the oft-cited assertion that the effects of puberty blockers are fully reversible. Indeed, the only study to date that has addressed this in sheep, suggests that this is not the case.”

10. Although the RCH guideline is badged as “Version 1.4 (2023)”, its 70-item reference list does not include any studies after 2018. Since 2019, a number of European countries have published the results of independent systematic reviews of the evidence base—the gold standard for testing the data said to support treatment.