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An independent politician in Australia urges that a state gender clinic be checked for treatment bias

Photo by Rob Martin on Unsplash

Psychiatry is not enough

Independent MP Frank Pangallo has called for a more searching review of the youth gender clinic at the Women’s and Children’s Hospital in the state of South Australia (SA).

On Friday, Women’s and Children’s Health Network chief executive Rebecca Graham cited an issue with pre-treatment assessment of young people at the Gender Diversity clinic and announced an internal review of uncertain scope.

Mr Pangallo, whose campaign for an SA parliamentary inquiry into gender medicalisation of minors was frustrated last year by the state’s centre-left Premier Peter Malinauskas, told GCN he feared “another whitewash.”

Mr Pangallo, a member of the upper house of the SA parliament, said the review of the clinic should scrutinise the assessment process for bias towards the contentious “gender-affirming” treatment model.

“The LGBTQ+ activists will now be lobbying hard to have the review watered down,” he said.

“The federal and state government are refusing to put the interests of young people with gender dysphoria first in this uncontrolled social experiment.”

Ms Graham told ABC News on Friday that the 2023 SA Statewide Gender Diversity Model of Care required a minor to be assessed by a psychiatrist before gender-affirming medical treatment.¹

In 2023-24, she said, 22 patients aged between 11 and 18 had been assessed not by a psychiatrist but by mental health clinicians such as a psychologist or a nurse.²

Ms Graham said retrospective psychiatric assessments were offered in these 22 cases and “no adverse outcomes” were found. The hospital has reportedly increased the availability of psychiatry at the clinic.

Ms Graham made a point of saying that assessment not involving a psychiatrist complies with “national standards”—presumably a reference to the “Australian standards of care” issued in 2018 by the gender-affirming clinic at the Royal Children’s Hospital (RCH) Melbourne.

In the same vein, SA Health Minister Chris Picton told ABC News that the 2023 SA model of care was “more stringent” than the de facto national standards from RCH Melbourne.

It is unclear to what extent the SA model of care—reportedly “co-designed” with the trans community—has been implemented.

In her ABC News interview Ms Graham made contradictory statements about this. She said variously that the model of care was “not implemented properly,” that “we will be implementing [it],” and “we have implemented the model of care.”

She said the review would check the gender clinic’s “compliance against the model of care in detail.”

“No new prescriptions for cross-sex hormones have been issued to children since the controversial [UK] Tavistock gender clinic was replaced a year ago, NHS leaders have revealed.”—Science editor Ben Spencer, news report, The Times, 5 April 2025

“The new NHS children’s gender service is prioritising ‘holistic’ care for children with gender dysphoria rather than fast-tracking them onto hormones, an accusation levelled at the Tavistock’s Gender Identity Development Service (GIDS) before it closed on March 31 last year.

“The [new NHS] service—which is running at Great Ormond Street in London, Alder Hey in Liverpool and Bristol Royal Hospital for Children—has also prescribed no new puberty blockers, which are banned until a new clinical trial starts later this year, pending ethical approval.

“It marks a fundamental switch in approach to the treatment of children with gender dysphoria [in England], with doctors slowing down the route to prescribing hormonal drugs. Between April 2018 and December 2022, 20 per cent of patients referred to GIDS were put on puberty blockers, cross-sex hormones or both.”

Call the psychiatrist?

Despite the recent focus on psychiatric assessment by South Australian health authorities, SA Health’s 2023 State-wide Gender Diversity Model of Care appears to lack an explicit rule that a minor must be assessed by a psychiatrist before access to puberty blockers or cross-sex hormones.

The SA model for the child and adolescent gender clinic cites “psychiatry assessment and opinion for medical management” as one of the key services on offer, but the emphasis of the document is multidisciplinary teamwork, with a specific reference to the “staffing model” set out in the RCH standards.

Under the heading “mental health clinicians,” the disciplines listed for the youth gender clinic are “social worker plus psychologist and/or mental health nurse,” so it would seem unsurprising that such clinicians did the assessment in the case of the 22 minors flagged by the hospital network official, Ms Graham.

Apart from diagnosis, the relevant role of the “child and adolescent psychiatrist” stated by the model of care is to, “Contribute to assessment of [the] adolescent’s capacity to provide informed consent to medical therapy…”

Both the paediatrician and the paediatric endocrinologist are to, “Assess adolescent capacity to consent to medical therapy in conjunction with [a] mental health clinician…”

Under “elements of care,” the SA model says that multidisciplinary assessment “generally involves more than one clinic appointment to allow for initial psychiatric assessment and diagnosis of gender dysphoria prior to medical assessment and management.”

“Assessment of psychosocial readiness and eligibility for medical therapy is based upon current clinical guidelines and standards of care, and determined by clinical consensus of the [multidisciplinary team] following multidisciplinary assessment.”

The SA state model is, if anything, less stringent than the 2018 RCH standards because, being more recent, it reflects the more radical, further “depathologised” variant of the gender-affirming treatment approach.

In this rights-driven approach internationally, psychiatrists may be seen as “gatekeepers” who obstruct access to desired treatment and pathologise the inviolable trans identity of minors who seek not a medical cure but personalised “embodiment goals.”

“Note that although many people who are TGDNB [trans, gender-diverse and non-binary] or gender-questioning experience gender dysphoria, not all do. Gender dysphoria is therefore not a prerequisite for service access or service provision.”—2023 SA Health model of care, child and adolescent service

“If gender dysphoria is not diagnosed, or where medical therapy is not indicated or where a non-medical pathway is requested, the person may continue to receive specialised service supports or may be referred for community-based or other hospital-based supports as clinically indicated.”

Distress optional?

The SA model of care sends mixed messages (see above) as to whether a diagnosis of gender dysphoria—a psychiatric diagnosis which is supposed to confirm “clinically significant distress”—is required before a minor can access medical treatment.

The model, which covers adults as well as minors, generally suggests that medical treatment is available for the more recent, depathologised and non-psychiatric diagnosis of “gender incongruence,” which does not have to involve any distress at all. This raises two questions—what medical condition is being treated and why would diagnosis require a psychiatrist?³

At one point, the SA model refers to trans, gender-diverse and non-binary people, and provision of “timely care for their experience of gender diversity or gender incongruence.”

The SA model of care also appears to contemplate surgery for minors in the public health system, which would be the most radical step yet in Australia.

“In cases where surgical affirmation is clinically indicated for the young person prior to transition to adult services (e.g. for young people under 18 years), referral may be made to the adult service for surgical assessment, and care provided in liaison with the adult service,” the SA model says.⁴

This section does not make clear whether the clinical distress of gender dysphoria is required for a minor to go down the surgical path.

But the SA model does appear to stipulate assessment by a psychiatrist before any “person” gets surgery.⁵

“The psychiatrist will confirm the diagnosis of gender dysphoria/incongruence, assess for any co-existing mental illness, and optimise any mental illness treatments prior to surgical intervention,” the model says in its discussion of “gender diversity surgical services.”

The RCH de facto national standards suggest “top surgery” or double mastectomy may be “appropriate” for girls aged 16 and older; in practice, RCH has reportedly referred 15-year-olds to private surgeons for this procedure.

Yet the RCH document does not recommend the more radical option of genital surgery for minors, noting the “greater risks with such major surgery, as well as the impacts on the adolescent’s long-term sexual function and reproductive potential.”

By contrast, the broad term “surgical affirmation” used by the SA model of care in the context of minors does not rule out genital surgery and stipulates no minimum age.

In this, it is broadly in line with the radical 2022 standards of care (SOC-8) issued by the World Professional Association for Transgender Health (WPATH), a hybrid professional-activist lobby.

Under political pressure from the US Biden administration, WPATH abandoned all minimum ages for surgery with adolescents in SOC-8, apart from drastic genital surgery to create a pseudo-penis for a female.

The SOC-8 guideline, cited by the SA model of care, is also tainted by revelations that WPATH suppressed systematic reviews which showed how weak and uncertain the evidence was for gender medicalisation, while claiming that a lack of studies ruled out a systematic review of the evidence said to support treatment of adolescents.

As for the 2023 SA model of care, it states that “new evidence must continue to be reviewed as part of ongoing monitoring to ensure that future service delivery models and clinical pathways continue to be evidence-based.”

Yet the SA document makes no mention of the systematic reviews undertaken independently by Finland, England and Sweden since 2018.

Those reviews found the evidence base for hormonal treatment of gender-distressed minors to be very weak and uncertain. As a result, those three jurisdictions adopted a more cautious treatment policy than is proposed by the SA model of care.

GCN put questions to the office of SA Health Minister Picton and the Women’s and Children’s Hospital Network

1. The nature of the treatment was not specified. Gender-affirming medical treatment embraces hormonal interventions (puberty blockers and cross-sex hormones) as well as surgical interventions.

2. The Advertiser reported Ms Graham as saying that staff had identified the assessment issue.

3. In the section of the SA model dealing with “gender diversity surgical services,” these procedures would be open to trans, gender-diverse and non-binary people “with gender dysphoria or gender incongruence.”

4. It is not made clear whether minors would need a diagnosis of gender dysphoria or simply gender incongruence to access surgery. Those judged “clinically indicated” for surgery are to be referred to the adult service for surgical assessment, which appears not to require a gender dysphoria diagnosis.

5. This requirement is stated in the section of the model dealing with surgical services as part of the Adult Gender Diversity Health Service. However, it appears logical to apply this requirement for psychiatric assessment to minors seeking surgery because they are to be referred to the adult service for surgical assessment.