Thank you Bernard. This is an excellent development. I am a retired lawyer who practised primarily in the defence of professional negligence claims for 39 years. The level of wilful malpractice in this area of ‘ medicine’ is extraordinary and may well justify the award of exemplary damages over and above ordinary damages in recognition of the egregious disregard of the rights of these children. I am not surprised that gender transition now been identified by an experienced insurer as an obvious source of future catastrophic financial loss. In applying the exclusion and transferring the financial risks back to professionals responsible for this disaster, the insurer may have successfully achieved the deterrent so needed to bring this shameful episode to an end. Jennifer O’Brien
Thanks Jennifer. What puzzles me is the stance of those responsible for managing the risk of children’s hospital gender clinics. Is gender ideology so entrenched in the bureaucracy that nobody is willing to agitate for something to be done to insure state treasuries against future claims?
I have to wonder do the state governments not worry about future law suits with potentially huge pay out of tax payer money. Would there be no one there flagging this as a potential issue on the purely financial front?
This is fantastic news. The only way out of this obscenity is through the logic of the markets. Cold hard cash or rather the likelihood of losing a lot of it is the only thing that will snap a self-deluded/opportunistic profession out of this madness. I never thought I’d celebrate the work of actuaries but right now I’m immensely pleased they exist.
It's amazing that any US state would require insurers to cover a treatment that is supported only by non-evidence based recommendations (in your work and in the excellent peer reviewed investigative report by Block in BMJ, "Gender dysphoria in young people is rising—and so is professional disagreement").
Well, the US scene does seem wildly polarised politically. And one of the red flags about the trans medicine scene is that things keep on happening that would be unimaginable in any other sphere.
Understood, Guy. The non-activist clinicians who see difficulty with RCTs are assuming hormonal interventions still available as routine treatment as well as access to these drugs from online providers.
The MDA’s decision to withdraw insurance coverage for family doctors and specialists in private practice involved in recommendation and/or hormonal treatment of gender dysphoria in individuals under the age of 18 years is not surprising. The availability of ‘Insurance’, in its many forms, is based on the perceived risk.
It is interesting to ponder the outlined complex and time consuming requirements prior to the licensing of a new life-saving cancer therapy. Yet no such scrutiny prior to otherwise healthy children and young people undergoing irreversible sterilising and mutilating surgical interventions because of a possibly transient belief that they were "born in the wrong body".
Is gender medicine the exception & oncology the norm, in that the former was introduced as routine treatment without a good evidence base, whereas the latter requires clinical trials before treatment becomes routine?
The randomized controlled clinical trial is the is the gold-standard procedure for testing the efficacy and safety of experimental medical treatments.
This is the case in oncology and all disciplines of medicine.
An experimental intervention involving children and young people that results in irreversible sterility and surgical mutilation obviously demands the most extreme scrutiny.
This has not happened and I suspect there will come a day when accountability will be demanded.
I’m told there are ethical & practical problems with a true RCT but it’s striking that of the major gender clinic research projects none even use a comparison group offered treatment alternative to “gender-affirming” treatment. Ken Zucker, the gender dysphoria expert, suggests using waiting lists as a control group. Baseline measures would be taken when the kid joins the list, not when first seen by clinic. No sign of gender clinics taking up this idea.
Bernard, The only reason that there are problems with a randomized trial is that the activist clinicians have convinced themselves and gender dysphoric kids that “affirmative” treatment is the best treatment.
The only way a trial will succeed is if routine affirmative treatment is forbidden so that the only access is via the trial so patients would have the choice of no medication at all or a 50% chance of getting it if they entered the trial.
Activist’s would scream blue murder but surely this is better than castration or double mastectomies that may come to be regretted.
Bernard, as you state, there certainly are significant practical problems with undertaking a randomised controlled trial on the safety and efficacy of GD interventions but of course this does not provide carte blanche to proceed with what they’re doing.
The old adage of ‘do no harm’ is a great fallback in such situations.
The point you make for undertaking an ‘outcome trial’ of the two groups, essentially a transition cohort with a ‘delayed treatment’ (a puberty delayed treatment group essentially becoming an ‘experimental treatment’ group). This is complicated stuff and requires expertise well outside of my pay scale but surely those promoting childhood transition must be desperately seeking a thread of justification and credibility.
Yes, Vincent, "gender-affirming" research seems an oxymoron because those conducting it *already* know & have declared publicly that it is "life-saving" & there are no effective alternative treatments.
Bernard. I believe the difference is that the drugs used in gender treatments are freely available on the PBS in the case of estrogens and androgens or only with a restriction in the case of gonadotrophin releasing hormones. No written authority is required.
But most of these treatments are initiated in a public hospital so the hospital would need to approve the off label use.
Usually this would require a written submission with documentary evidence justifying the use.
The hospitals involved have obviously been snowed by the clinicians to accept flimsy incomplete evidence.
Thanks for that comment, Guy. I have asked the Royal Children's Hospital medicine whether or not there was ethics clearance before these hormonal interventions were introduced as routine, but they didn't answer.
Because these are usually one off applications, some evidence of activity and safety but not necessarily to the TGA/PBS standard but for this carte blanche indefinite approval that they appear to have received for gender drugs I would have thought they should demand rock solid evidence which they obviously have not received because there is none.
Perhaps this move from a professional indemnity firm may encourage, say AHPRA , or even appropriate specialist colleges, to approach legislators to introduce laws to ban medical intervention in minors. Such an approach , to protect future vulnerable children, may be relied upon to reduce their exposure in future class actions. Those bodies’ inactions , to date, may well invoke claims for reparations from not just State governments, but professional bodies whose duty of care could be deemed as compromised to date by their inaction
My hunch is that at this stage, the incentives & disincentives do not favour that kind of regulatory intervention. I suspect it will take some major litigation, serious catch-up reporting by media with big audiences, and consequent pressure on politicians to *do something*. How long that will take, who knows?
I am a retired GP with paediatric registrar training) with an interest in this medical facet ( childhood GD) of the “ gem” of Identity Politics and have been waiting and expecting/ hoping for the “ push back”, i,e., an inevitable challenge to the ideological, social science, based driver of gender identity/ fluidity , to come from the profession. The activists have been prepared to fight harder across all domains of Identity Politics and the longer it remains unchallenged, the stronger the beast gets. The woke take no prisoners.
In this “facet” of the “ gem” the $$$ ( cost of reparations from future class actions) are proving more to becoming the spearhead for the confrontation, than those bodies , say , the colleges and AHPRA, of my profession whose silence has been inexplicably protracted , given the evidence, or rather lack of evidence, known for so long. I can’t see why those bodies won’t likely be included in claims of failure to provide duty of care in inevitable class actions. I understand there are some thousand pending in the UK. I wonder if their comparable professional bodies are
I’m told AHPRA appears sympathetic to complaints against practitioners who are targeted as “transphobic”, although of course the complaint would be dressed up in other terms.
If the Tavistock Trust is the body to be the subject of UK class actions, does that not translate to State governments here in Australia becoming the recipients? If so, surely colluding bodies like the colleges and AHPRA ( that will be something of a delicious irony) could expect to be targeted?
I don’t know. The action against the Tavistock was judicial review. Potential claims against gender clinics (state governments) tend to involve civil claims of negligence.
A few reactions in the medical community in recent days, including a strong one from from the head of MDA, who has held prominent national positions before this role:
from this article: "AusPATH had been reassured by two other major insurers, Avant and Medical Indemnity Protection Society (MIPs), that they would continue to cover GPs prescribing hormones to transgender patients under 18."
"Dr Owen Bradfield, chief medical officer for Medical Indemnity Protection Society, told TMR via email that MIPS covered its members for gender-affirming care provided to adolescents.
“However, this is subject to a general requirement in the MIPS’ Indemnity Insurance Policy that all members must have the appropriate training, qualifications, and experience in relation to any healthcare services they provide, and that they adhere to the Medical Board of Australia’s Code of Conduct,” he said.
“This requirement applies to all members providing any healthcare, not just those providing gender-affirming healthcare.”
MIPS had no current plans to remove this cover from its members, Dr Bradfield said."
Thanks to all who have been advocating in this important space. It is having a major impact amongst my peers; the hardcore ideologues will double down, others will be sobered and review their involvement. Keep it up
Just to clarify - any new treatments ("any initial prescribing") will not be covered (including for doctors in hospitals) but ongoing prescription of current treatment plan is?
Still trying to clarify the detail, Nina. But it seems private docs covered if they initiate blockers, not if they initiate cross-sex hormones. But if private doc assesses a kid as suitable for "gender transition" (which MDA defines as cross-sex hormones or surgery), doc is not covered against claims arising from that assessment.
Private doctors are only covered if the initial assessment was conducted in a multidisciplinary hospital clinic. So if a AUSPATH/TransHub listed GP or another type of community specialist starts the prescribing, none of that patient's future doctors would be indemnified by MDA.
This has had significant ripples in the medical community, practitioners are scrambling and afraid for their own wellbeing, I do hope this translates to patient wellbeing.
It seems the the more recent Family Legal Paper was presented to the medical indemnity organisations and may have had an impact in this 1st decision. I hope that other's follow suit. If other indemnifiers don't adopt a similar stance, they will have to wear the long term risk of community 'affirming' doctors who change ships.
Thank you Bernard. This is an excellent development. I am a retired lawyer who practised primarily in the defence of professional negligence claims for 39 years. The level of wilful malpractice in this area of ‘ medicine’ is extraordinary and may well justify the award of exemplary damages over and above ordinary damages in recognition of the egregious disregard of the rights of these children. I am not surprised that gender transition now been identified by an experienced insurer as an obvious source of future catastrophic financial loss. In applying the exclusion and transferring the financial risks back to professionals responsible for this disaster, the insurer may have successfully achieved the deterrent so needed to bring this shameful episode to an end. Jennifer O’Brien
Thanks Jennifer. What puzzles me is the stance of those responsible for managing the risk of children’s hospital gender clinics. Is gender ideology so entrenched in the bureaucracy that nobody is willing to agitate for something to be done to insure state treasuries against future claims?
I have to wonder do the state governments not worry about future law suits with potentially huge pay out of tax payer money. Would there be no one there flagging this as a potential issue on the purely financial front?
I wish medical ethics not risk of being sued for medical harm was driving this decision. However, a win for protecting children is a win.
Would this decision exclude GP’s in Victorian schools from prescribing puberty blockers?
I guess you could say "good intentions" got us in this mess, and if it's economic self-interest that gets us out of it, so be it.
GPs assessing kids for gender transition -- wherever that's done, I assume -- & copping a claim would not be protected by this indemnity insurer.
This is fantastic news. The only way out of this obscenity is through the logic of the markets. Cold hard cash or rather the likelihood of losing a lot of it is the only thing that will snap a self-deluded/opportunistic profession out of this madness. I never thought I’d celebrate the work of actuaries but right now I’m immensely pleased they exist.
It's amazing that any US state would require insurers to cover a treatment that is supported only by non-evidence based recommendations (in your work and in the excellent peer reviewed investigative report by Block in BMJ, "Gender dysphoria in young people is rising—and so is professional disagreement").
Well, the US scene does seem wildly polarised politically. And one of the red flags about the trans medicine scene is that things keep on happening that would be unimaginable in any other sphere.
I guess RCH would have been told activist & safety offshore, chiefly the Dutch clinic & its publications.
Understood, Guy. The non-activist clinicians who see difficulty with RCTs are assuming hormonal interventions still available as routine treatment as well as access to these drugs from online providers.
The MDA’s decision to withdraw insurance coverage for family doctors and specialists in private practice involved in recommendation and/or hormonal treatment of gender dysphoria in individuals under the age of 18 years is not surprising. The availability of ‘Insurance’, in its many forms, is based on the perceived risk.
It is interesting to ponder the outlined complex and time consuming requirements prior to the licensing of a new life-saving cancer therapy. Yet no such scrutiny prior to otherwise healthy children and young people undergoing irreversible sterilising and mutilating surgical interventions because of a possibly transient belief that they were "born in the wrong body".
Is gender medicine the exception & oncology the norm, in that the former was introduced as routine treatment without a good evidence base, whereas the latter requires clinical trials before treatment becomes routine?
The randomized controlled clinical trial is the is the gold-standard procedure for testing the efficacy and safety of experimental medical treatments.
This is the case in oncology and all disciplines of medicine.
An experimental intervention involving children and young people that results in irreversible sterility and surgical mutilation obviously demands the most extreme scrutiny.
This has not happened and I suspect there will come a day when accountability will be demanded.
I’m told there are ethical & practical problems with a true RCT but it’s striking that of the major gender clinic research projects none even use a comparison group offered treatment alternative to “gender-affirming” treatment. Ken Zucker, the gender dysphoria expert, suggests using waiting lists as a control group. Baseline measures would be taken when the kid joins the list, not when first seen by clinic. No sign of gender clinics taking up this idea.
Bernard, The only reason that there are problems with a randomized trial is that the activist clinicians have convinced themselves and gender dysphoric kids that “affirmative” treatment is the best treatment.
The only way a trial will succeed is if routine affirmative treatment is forbidden so that the only access is via the trial so patients would have the choice of no medication at all or a 50% chance of getting it if they entered the trial.
Activist’s would scream blue murder but surely this is better than castration or double mastectomies that may come to be regretted.
Bernard, as you state, there certainly are significant practical problems with undertaking a randomised controlled trial on the safety and efficacy of GD interventions but of course this does not provide carte blanche to proceed with what they’re doing.
The old adage of ‘do no harm’ is a great fallback in such situations.
The point you make for undertaking an ‘outcome trial’ of the two groups, essentially a transition cohort with a ‘delayed treatment’ (a puberty delayed treatment group essentially becoming an ‘experimental treatment’ group). This is complicated stuff and requires expertise well outside of my pay scale but surely those promoting childhood transition must be desperately seeking a thread of justification and credibility.
Yes, Vincent, "gender-affirming" research seems an oxymoron because those conducting it *already* know & have declared publicly that it is "life-saving" & there are no effective alternative treatments.
Bernard. I believe the difference is that the drugs used in gender treatments are freely available on the PBS in the case of estrogens and androgens or only with a restriction in the case of gonadotrophin releasing hormones. No written authority is required.
But most of these treatments are initiated in a public hospital so the hospital would need to approve the off label use.
Usually this would require a written submission with documentary evidence justifying the use.
The hospitals involved have obviously been snowed by the clinicians to accept flimsy incomplete evidence.
Thanks for that comment, Guy. I have asked the Royal Children's Hospital medicine whether or not there was ethics clearance before these hormonal interventions were introduced as routine, but they didn't answer.
I don’t believe they would go to an ethics committee. In my Hospital you would need to apply to the Hospital Medicines Formulary committee.
It would be good to ask them how they justify using drugs only approved for Breast Cancer and Prostate cancer, in children.
What kind or quality of evidence would a medicines formulary committee require?
Because these are usually one off applications, some evidence of activity and safety but not necessarily to the TGA/PBS standard but for this carte blanche indefinite approval that they appear to have received for gender drugs I would have thought they should demand rock solid evidence which they obviously have not received because there is none.
Perhaps this move from a professional indemnity firm may encourage, say AHPRA , or even appropriate specialist colleges, to approach legislators to introduce laws to ban medical intervention in minors. Such an approach , to protect future vulnerable children, may be relied upon to reduce their exposure in future class actions. Those bodies’ inactions , to date, may well invoke claims for reparations from not just State governments, but professional bodies whose duty of care could be deemed as compromised to date by their inaction
My hunch is that at this stage, the incentives & disincentives do not favour that kind of regulatory intervention. I suspect it will take some major litigation, serious catch-up reporting by media with big audiences, and consequent pressure on politicians to *do something*. How long that will take, who knows?
I am a retired GP with paediatric registrar training) with an interest in this medical facet ( childhood GD) of the “ gem” of Identity Politics and have been waiting and expecting/ hoping for the “ push back”, i,e., an inevitable challenge to the ideological, social science, based driver of gender identity/ fluidity , to come from the profession. The activists have been prepared to fight harder across all domains of Identity Politics and the longer it remains unchallenged, the stronger the beast gets. The woke take no prisoners.
In this “facet” of the “ gem” the $$$ ( cost of reparations from future class actions) are proving more to becoming the spearhead for the confrontation, than those bodies , say , the colleges and AHPRA, of my profession whose silence has been inexplicably protracted , given the evidence, or rather lack of evidence, known for so long. I can’t see why those bodies won’t likely be included in claims of failure to provide duty of care in inevitable class actions. I understand there are some thousand pending in the UK. I wonder if their comparable professional bodies are
I’m told AHPRA appears sympathetic to complaints against practitioners who are targeted as “transphobic”, although of course the complaint would be dressed up in other terms.
If the Tavistock Trust is the body to be the subject of UK class actions, does that not translate to State governments here in Australia becoming the recipients? If so, surely colluding bodies like the colleges and AHPRA ( that will be something of a delicious irony) could expect to be targeted?
I don’t know. The action against the Tavistock was judicial review. Potential claims against gender clinics (state governments) tend to involve civil claims of negligence.
A few reactions in the medical community in recent days, including a strong one from from the head of MDA, who has held prominent national positions before this role:
https://www1.racgp.org.au/newsgp/professional/insurance-cut-for-gender-affirming-care-sends-such
https://www.ausdoc.com.au/news/mdo-defends-restricting-cover-for-doctors-treating-kids-with-gender-dysphoria/
https://www.smh.com.au/healthcare/what-s-the-real-risk-gender-transition-insurance-cover-cut-for-gps-20230523-p5damx.html
from this article: "AusPATH had been reassured by two other major insurers, Avant and Medical Indemnity Protection Society (MIPs), that they would continue to cover GPs prescribing hormones to transgender patients under 18."
https://www.medicalrepublic.com.au/mdos-transphobic-move-on-gender-affirming-care/92277
with this comment:
"Dr Owen Bradfield, chief medical officer for Medical Indemnity Protection Society, told TMR via email that MIPS covered its members for gender-affirming care provided to adolescents.
“However, this is subject to a general requirement in the MIPS’ Indemnity Insurance Policy that all members must have the appropriate training, qualifications, and experience in relation to any healthcare services they provide, and that they adhere to the Medical Board of Australia’s Code of Conduct,” he said.
“This requirement applies to all members providing any healthcare, not just those providing gender-affirming healthcare.”
MIPS had no current plans to remove this cover from its members, Dr Bradfield said."
Thanks to all who have been advocating in this important space. It is having a major impact amongst my peers; the hardcore ideologues will double down, others will be sobered and review their involvement. Keep it up
Just to clarify - any new treatments ("any initial prescribing") will not be covered (including for doctors in hospitals) but ongoing prescription of current treatment plan is?
Still trying to clarify the detail, Nina. But it seems private docs covered if they initiate blockers, not if they initiate cross-sex hormones. But if private doc assesses a kid as suitable for "gender transition" (which MDA defines as cross-sex hormones or surgery), doc is not covered against claims arising from that assessment.
Thankyou. Thankyou as well for publishing this!
Private doctors are only covered if the initial assessment was conducted in a multidisciplinary hospital clinic. So if a AUSPATH/TransHub listed GP or another type of community specialist starts the prescribing, none of that patient's future doctors would be indemnified by MDA.
This has had significant ripples in the medical community, practitioners are scrambling and afraid for their own wellbeing, I do hope this translates to patient wellbeing.
It seems the the more recent Family Legal Paper was presented to the medical indemnity organisations and may have had an impact in this 1st decision. I hope that other's follow suit. If other indemnifiers don't adopt a similar stance, they will have to wear the long term risk of community 'affirming' doctors who change ships.
Dear GP, I'd like to talk to you about this in confidence. Could you please call me on 0424 263 733.
thanks, BL
Great yarn
Thanks, mate! B
Included in the actions?
Patients can sue a Public Hospital. This new policy will have the effect of putting all the risk on the public sector and therefore the taxpayer.