Exposed

Medical insurance firm cuts back protection for doctors who face court claims over paediatric transition

Photo by Tom Caillarec on Unsplash

Australian doctors in private practice may come under pressure to cease involvement in medicalised gender change of minors following a landmark insurance decision that stresses the significant risk of litigation.

“In response to the high risk of claims arising from irreversible treatments provided to those who medically and surgically transition as children and adolescents, [medical indemnity insurer] MDA National is restricting cover for practitioners in private practice,” the insurer says in an email to members with this exposure.

There is intense international debate about the safety and efficacy of medical transition for an unprecedented number of teenagers, mostly female and presenting with an atypical late-onset form of gender dysphoria, a once-rare condition of distress in the sexed body.

“I am surprised by the shortage of studies in this field [of paediatric transition]. We found no randomised trials, and only 24 relevant observational studies”—Professor Jonas F Ludvigsson of the Karolinska Institute, who took part in Sweden’s systematic review of the evidence base, media statement, 19 April 2023

No payment

The MDA National email to doctors seeing gender dysphoric youth says: “[From July 1, we] will not cover you or make a payment when the claim against you arises in any way out of your assessment that a patient under the age of 18 years is suitable for gender transition.”

The insurer, which has 54,000 health professional members, also says it will no longer cover doctors if they face a claim after “initiating prescribing of gender affirming hormones for any patient under the age of 18 years.

“We consider it appropriate that the assessment and initial prescribing for patients transitioning under the age of 18 years occurs with the support and management of a multi-disciplinary team in a hospital setting.”

In answer to questions from GCN, a spokeswoman for MDA National said: “We have been very targeted in the risks we have sought to exclude, which means that members will still be able to provide a broad range of healthcare to children and adolescents with gender dysphoria.”

Claims arising from puberty blocker treatment were “not currently excluded from cover”, although the insurer understood “there is some uncertainty around the effects of longer-term use of puberty blockers [and] not all effects of puberty blockers are reversible.”

Asked about cover for under-18 trans surgery, such as mastectomy, the spokeswoman said the exclusion would apply to claims arising from a surgeon assessing a patient as suitable for such operations.

“We will still cover claims arising from the ongoing prescription of cross-sex hormones in line with the regime prescribed by the appropriate [medical] specialist,” she said.

“However, we will not indemnify any member for claims that arise out of an assessment that a child or adolescent was suitable for transition, or for claims that arise out of the initial prescribing, even if these activities were performed within a multi-disciplinary team within a hospital.

“Members of such a multi-disciplinary team should ensure they have cover from the hospital, their employer or from another indemnity provider.”

These new exclusions in MDA National’s professional indemnity policies affect family doctors and specialists in private practice. Under Australian law, physicians cannot practice in fields of medicine where they lack insurance cover.

If MDA National stands firm against any transgender activist backlash, and the remaining medical indemnity funds adopt similar carve-outs, the effect would be to concentrate the legal risk in state-funded children’s hospital gender clinics.

Dr Philip Morris, president of Australia’s National Association of Practising Psychiatrists, welcomed news of the indemnity insurance decision.

“We are encouraged by the idea that the medical indemnity people have identified that gender transition is a significant event and may be irreversible, and therefore the actual treatment should only be conducted after a multidisciplinary assessment in a hospital environment,” Dr Morris told GCN.

No consensus

Copies of the NAPP guide to managing gender dysphoria for young people—which favours a range of ethical psychological approaches over uncertain medical interventions—are being sent to politicians across Australia; ministers and shadow ministers for health and mental health; senior health officials; children’s commissioners; medical, psychological and social work societies; and youth gender clinics.

“Currently, while some individuals report a successful transition, we are not aware of published long-term outcome studies that have followed up adults who have undergone childhood or adolescent transition that show substantial benefit,” the guide says.

“As a consequence, 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.”

Video: ‘The testosterone really worsened my mental health’—detransitioners’ stories, via Sex Matters

Fast-track treatment

There is no good Australian data on the extent of medical transition of minors in the private health sector, but specialist gender clinics in public children’s hospitals have long waiting lists, and trans rights activists have campaigned to mainstream hormonal interventions through local family doctors and hospitals.

There are anecdotal reports of family doctors using the fast-track, American-style “informed consent” model to prescribe cross-sex hormones for patients under 18, potentially at odds with the law as declared by Australia’s Family Court. (That court has approved trans mastectomies for females as young as 15.)

Unlike the traditional medico-legal concept of informed consent, the trans variant is driven by patient demand and does not require a mental health assessment, which might pick up reasons to put transition on hold and instead treat other conditions underlying gender distress.

A physician who follows the gender clinic controversy told GCN he believed “this whole treatment area [of medicalised gender change for minors] has gone ahead without adequate evidence of, firstly, efficacy, and, secondly, safety.

“If we were introducing a treatment for cancer, for example, we have to prove it is efficacious in multiple trials,” he said.

“You have to do phase-one trials, phase-two trials, and then a randomised trial before they would even consider allowing people to have widespread access to [a new cancer treatment].”

The physician said the key outcome for researchers to assess paediatric transition should be suicide prevention, because gender clinicians “tell everyone, without evidence, that [transition] prevents suicide.

“It’s all very well to ask [participants in a study], ‘Are you feeling better?’ You can’t measure that. That’s not a hard endpoint.”

In Finland, Sweden and England, systematic reviews of the scientific literature on paediatric gender transition have found the evidence base to be sparse, weak and uncertain—not sufficient to justify routine use outside a formal research setting.

“We have members who have been accused of transphobia for asking to see the evidence behind medicalised gender treatments. But it is very clear the evidence is weak”—Dr Louise Irvine, retired family doctor and co-chairwoman of the Clinical Advisory Network on Sex and Gender, a group of clinicians in the UK and Ireland campaigning for more rigorous science on gender dysphoria, news article, The Sunday Times of London, 7 May 2023

“The level of fear is pretty strong among our members. We have [family doctors], nurses, midwives, physiotherapists, academics. But about half our members work in the psychiatric professions, because they have been at the sharp end of the risks of gender-affirming care and the lack of evidence.”

Counterpunch

While many Republican states in the U.S. champion bills to restrict paediatric transition, the Democratic-leaning state of Oregon has introduced legislation to entrench insurance cover for these hormonal and surgical interventions.

“[Oregon’s] House Bill 2002 defines gender-affirming treatment as ‘a procedure, service, drug, device or product that a physical or behavioural health care provider prescribes to treat an individual for incongruence between the individual’s gender identity and the individual’s sex assignment at birth’,” says a news report in National Review.

“The bill prohibits insurers from denying gender-related treatments deemed ‘medically necessary’ by a ‘physical or behavioural health care provider.’ Additionally, insurers may not exclude coverage of a ‘cosmetic service’ deemed ‘medically necessary,’ including facial feminisation surgeries, tracheal shaves, and hair-removal procedures. 

“The bill also requires insurance plans to cover “revisions to prior forms of gender-affirming treatment.” The director of the Oregon Department of Consumer and Business Services sent a letter to Oregon House Speaker Dan Rayfield stating that the department will clarify that the bill does require insurance companies to cover de-transition surgeries.”

Note: GCN sought comment from medical indemnity insurers Avant, Tego, the Medical Insurance Group Australia and the Medical Indemnity Protection Society. The gender-affirming lobby the Australian Professional Association for Trans Health was also asked for comment.