Doctors disagree

An Australian politician lets the cat out of the bag

Shannon Fentiman, health minister in Australia’s state of Queensland

The gist

Analysis

An Australian health minister, Shannon Fentiman, who is responsible for the busy gender clinic of the Queensland Children’s Hospital, has acknowledged the lack of consensus on how to treat gender dysphoria.

Four words stood out in Ms Fentiman’s otherwise cagey, scripted response to a question in state parliament about the source of the evidence justifying the puberty blockers and cross-sex hormones given to minors by the Brisbane-based clinic.

“Whilst acknowledging that best practices rely on some aspects of transgender health care and there is not consensus [Emphasis added], the work continues,” she said on November 30.

Child and adolescent psychiatrist Dr Jillian Spencer, who has been calling for an independent federal inquiry into the care of gender dysphoric youth, welcomed Ms Fentiman’s concession reflecting the state of medical opinion—a concession not forthcoming from Australia’s other health ministers.

“It is such a relief to have [Queensland’s] health minister finally acknowledge that there is not consensus regarding the best practices for transgender healthcare,” Dr Spencer told GCN.

Dr Spencer is a critic of the “gender-affirming” treatment approach followed by the Queensland gender clinic. Earlier this year she was suspended from clinical duties at the children’s hospital reportedly after a patient lodged a complaint of “transphobia”.

“The minister says that the work of the [clinic] continues despite the lack of consensus on best practice for transgender healthcare,” Dr Spencer said.

“Why is the work of the [clinic] continuing if there is no consensus? Shouldn’t we be more careful than that—especially when the health of children is at stake? Parents want cautious and evidence-based healthcare for their children.

“The children and parents of Queensland deserve to have paediatric gender services that are based on a systematic review of the research evidence similar to what is happening in the UK with the Cass Review.”

She challenged the advice given to Ms Fentiman that the work of the Queensland gender clinic represented “international best practice”.

“[It appears her advisers] have failed to let her know that, internationally, when [countries such as Finland, Sweden and the UK] have conducted independent, systematic reviews of the research literature, they have moved away from an affirmative approach to prioritise psychosocial interventions rather than puberty blockers and cross-sex hormones”.

“A new front in the struggle over transgender issues has opened up. Two [US] medical malpractice lawsuits, each levied by a plaintiff who regrets having undergone medication-based gender-transition treatment—one at age 14—have taken aim at the American medical establishment’s support for prescribing such drugs to minors.”—Journalist Benjamin Ryan, news report, New York Sun, 5 December 2023

The detail

Behind the scenes

Minister Fentiman remarked on the lack of medical consensus during her short November 30 reply to Robbie Katter MP, whose question was prompted by Ms Fentiman’s earlier reassurance that care at the gender clinic was “of very high quality and based on the best available evidence.”

The minister’s surprising concession to critics of the gender-affirming approach—the approach enforced at the gender clinic—chimes with the reference by Queensland’s chief psychiatrist, Dr John Reilly, to plans for an “independent review” of the clinic.

GCN has sought clarification on both points from the government; there was no reply.

Might Queensland be the first Australian jurisdiction to publicly acknowledge the force of the international debate about medicalised gender change for minors? Have there been frank discussions, even talk of doing something, in Ms Fentiman’s office or among her health and hospital officials?

The main focus now for Queensland’s governing Labor Party is re-election. In power since 2013, the party has shuffled its leadership as it prepares for the state poll scheduled for 26 October 2024.

It appears that Steven Miles, a former health minister, will succeed the long-serving Annastacia Palaszczuk as premier.

Ms Fentiman, a solicitor from the party’s left faction, was briefly in the running. Her narrative was change and renewal, a government with “the maturity to admit where we have fallen short.”

Does anyone think that concerns about gender medicine will have evaporated by next October?

Video: British politics has zeroed in on fears that gender non-conforming children, who otherwise might grow up lesbian or gay in healthy bodies, are being medicalised as ‘trans’

Affirmed by guidelines

Minister Fentiman’s November 30 defence of the gender clinic boiled down to its “adherence to peer-reviewed national and internationally accepted published practice clinical guidelines”.

She cited the latest, 8th edition of standards of care issued last year by the World Professional Association for Transgender Health (WPATH), which she said evinced “a rigorous and evidence-based approach”.

She also invoked the 2017 clinical guideline of the Endocrine Society, offering to get a copy for Mr Katter, who represents a minor party in the parliament.

And she cited a third document, the 2018 “Australian standards of care” issued by the Royal Children’s Hospital Melbourne.

Back in September, Ms Fentiman had said the gender medicine practised by the Queensland clinic was “an emerging field globally—no-one shies away from that—but the evidence base is sound.”

In fact, the evidence base for medicalised gender change for minors is very weak and uncertain, according to five independent systematic reviews since 2019 in Finland, Sweden, the United Kingdom (one review each for puberty blockers and cross-sex hormones) and the American state of Florida.

The founder of the Queensland gender clinic, Dr Stephen Stathis, recently conceded the complaint of sceptics that the evidence base for gender-affirming treatment is of low quality, although he argued this was not unusual in the field of child and adolescent psychiatry.

Lack of solid evidence has led gender-affirming clinicians and activists to rely heavily on treatment guidelines and position statements from medical organisations when claiming that puberty blockers, cross-sex hormones and surgery are “settled science”.

But systematic reviews are regarded as the highest form of evidence, while treatment guidelines and position statements—representing expert opinion or professional consensus—are the lowest.

And it’s arguable that gender-affirming treatment guidelines do not even reflect expert consensus, as Ms Fentiman’s arresting remark suggests.

The extent of health professional dissent from the gender-affirming model is masked because it is well known that critics will be smeared as “transphobic”, subjected to bad-faith complaints and have their careers put at risk.

If in truth there is no consensus, the treatment guidelines cited by Ms Fentiman are misleading and cannot justify the risky medical interventions given by the gender clinic.

It’s unclear how this contradiction in the minister’s November 30 statement arose. Does it reflect a confused briefing from her advisers and officials, or a belated awareness that gender-affirming medicine is hardly settled science?

Video: Family physician Dr Elizabeth McIntosh testifies in support of a bill to restrict medicalised gender change for minors in the US state of Ohio

Reviewphobia

In any case, the problem for Ms Fentiman is that her faith in those three treatment guidelines is misplaced.

The “rigorous” WPATH guideline process involved a chaotic last-minute abandonment of minimum ages for most hormonal and surgical interventions; the rationale appears to be to give clinicians better protection against malpractice suits.

Credible guidelines draw on a systematic review of the evidence. WPATH’s new chapter on adolescents—the group that is the focus of international concern—involved no such review. WPATH pleaded the scarcity of studies on early medical intervention.

And yet early medical intervention is what the guideline recommends. Perhaps WPATH was worried about the predictable output of a systematic review, not the meagre input.

Scarcity of studies did not prevent Sweden’s systematic review of the evidence. Its literature search began with almost 10,000 research abstracts and identified just 24 relevant studies for evaluation.

One of the experts involved, Professor Mikael Landén of the Karolinska Institute said—

“Against the background of almost non-existent long-term data, we conclude that [puberty blocker] treatment in children with gender dysphoria should be considered experimental treatment rather than standard procedure. This is to say that treatment should only be administered in the context of a clinical trial under informed consent.”

The gender clinic that Ms Fentiman celebrates for its “life-changing care” gives puberty blockers as routine treatment. And remember, Queensland’s parliament has been assured by the minister that “the evidence base is sound”.

A matter of trust

Ms Fentiman also cited the 2018 “Australian standards of care” from the Royal Children’s Hospital Melbourne (RCH), noting its publication as a position statement in the Medical Journal of Australia (MJA).

But that cut-down version of the guideline, shielded by the journal’s pay wall, contains an admission not found in the full guideline which is the document that is readily available on the hospital website and relied on by youth gender clinics across Australia.

The MJA version says: “The scarcity of high-quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations.”

Earlier this year, GCN put this claim to Professor Gordon Guyatt, a pioneer of evidence-based medicine and the GRADE system for rating evidence quality.

“[That claim] is enough for me to say this is not a trustworthy guideline”, Professor Guyatt said.

The RCH guideline was considered for inclusion in the National Health and Medical Research Council’s online portal Australian Clinical Practice Guidelines but did not qualify.

“At the screening stage it was determined that the 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,” a spokeswoman for the NHMRC said in 2021.

Screenshot: Advice from the 2018 RCH “Australian standards of care” document

The 2018 RCH document incorrectly told clinicians it was no longer necessary to seek court approval before starting a minor on irreversible cross-sex hormones. The advice in the document was updated, but without a citation to the Family Court decision that states the law correctly. A key rationale for the creation of the RCH standards was to persuade judges that the science was solid enough for them to reduce their supervision of treatment decisions.

Divided opinion

Also in 2021, the Royal Australian and New Zealand College of Psychiatrists (RANZCP), which had previously endorsed the RCH guideline, issued a new more cautious policy on gender dysphoria.

Its policy says that “evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate.” (Note: After posting this article, I was alerted to an update of the RANZCP’s gender dysphoria policy, which I will report elsewhere.)

In its recently updated guide, the National Association of Practising Psychiatrists says “there is no consensus that medical treatments such as the use of puberty-blocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psycho-social adjustment.”

No consensus, but the Queensland Children’s Hospital requires health professions to follow the gender-affirming model rather than allowing a neutral therapeutic approach.

We know this because psychiatrist Dr Spencer has raised concerns—initially within the hospital, then publicly—about the potential harm done to minors by unthinking “affirmation”. She even wrote to the minister about this.

“I started testosterone five years ago today. After 4+ years of weekly injections to maintain such dangerously high hormone levels, I had elevated liver enzymes, heightened red blood cell counts, and regular heart palpitations. I am so grateful I stopped when I did.”—American detransitioner Morgan, tweet, 4 December 2023

Low-quality advice

Ms Fentiman’s third guideline, from the Endocrine Society, has an important feature that her advisers appear to have overlooked.

Unlike the RCH document, the 2017 Endocrine Society guideline did rate the quality of evidence supporting their treatment recommendations.

Five of the society’s six recommendations on puberty blockers depend on evidence rated as “low quality”.

The sixth recommendation—for administering blockers in early puberty, as is done at Queensland’s gender clinic—rests on “very low-quality” evidence, the lowest possible rating. Awkward but important details, rarely mentioned.

Also unmentioned is the society’s careful disclaimer that its “guidelines cannot guarantee any specific outcome, nor do they establish a standard of care.” Not helpful for those demanding a monopoly for gender-affirming care.

In July this year, the society’s president, Dr Stephen R Hammes, made the claim that, “More than 2,000 studies published since 1975 form a clear picture: Gender-affirming care improves the well-being of transgender and gender-diverse people and reduces the risk of suicide.”

This, he said in a letter to The Wall Street Journal, was the evidence used by the society in its “rigorous process” to develop the 2017 treatment guideline.

He provoked a dramatic and humiliating response—a letter of sharp dissent signed by 21 clinicians and researchers from nine countries involved in the care of teenagers with gender distress.

Among them was Finland’s reformist pioneer of gender medicine, Professor Riittakerttu Kaltiala, whistleblower clinicians from England’s Tavistock clinic Dr Anna Hutchinson and Dr Anastassis Spiliadis, and Belgian expert on evidence-based medicine Dr Patrik Vankrunkelsven.

All systematic reviews to date, the letter’s authors pointed out, had “found the evidence for mental-health benefits of hormonal interventions for minors to be of low or very low certainty.”

“Dr Hammes’s claim that gender transition reduces suicides is contradicted by every systematic review, including the review published by the Endocrine Society, which states, ‘We could not draw any conclusions about death by suicide.’ There is no reliable evidence to suggest that hormonal transition is an effective suicide-prevention measure.

“The politicization of transgender healthcare in the US is unfortunate. The way to combat it is for medical societies to align their recommendations with the best available evidence—rather than exaggerating the benefits and minimizing the risks.”

So, is Minister Fentiman confident that she had been given an apolitical and accurate summary of the benefits and risks of treatment at Queensland’s gender clinic?

“Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies.”—Psychiatrist Dr Roberto D’Angelo, article, Journal of Medical Ethics, 2023

Just the one

Also, in the spirit of governments owning up to mistakes, Ms Fentiman might revisit something she said about Dr Spencer.

On September 14, Mr Katter raised the issue of the compulsion for doctors to use the gender-affirming model with dysphoric children, and asked, “Will the minister intervene to restore the ability of doctors—including Dr Jillian Spencer, who has been stood down—to use their professional medical discretion when treating gender dysphoric children?”

Ms Fentiman replied—

“I understand there have been a number of complaints made by patients in relation to Dr Spencer. These complaints are subject to a number of HR processes within Children’s Health [which runs the hospital] as well as referrals to [the health professions regulator] Ahpra and the Health Ombudsman.”

A possible implication of Ms Fentiman’s comment is that Dr Spencer had engaged in a pattern of conduct attracting multiple complaints from patients.

Last month, thanks to a right of reply mechanism, a correction from Dr Spencer was placed on the parliamentary record—

“The minister’s statement suggests that I am the subject of a number of patient complaints. That is incorrect. There is only one patient complaint lodged against me.”

“After being expelled from my master’s degree for speaking out about the impact of gender ideology on child safeguarding, I am extremely pleased to announce that I have agreed a settlement with the UK Council for Psychotherapy. [The council] have published a formal statement protecting therapists who believe in biological reality and stand against irreversible medicalisation of children. They say training institutions should never discriminate against students on this basis.”—UK lawyer turned trainee therapist James Esses, tweet, 11 December 2023

GCN sought comment from Ms Fentiman and RCH