Flying blind

There is a shadow of doubt over the campaign to mainstream hormone drugs for teenagers

Photo by Andra C Taylor Jr on Unsplash

GP leadership in doubt

There is confusion over whether Australia’s largest medical defence organisation, Avant, will underwrite the gender clinicians’ campaign to expand and fast-track irreversible cross-sex hormone drugs for 16- and 17-year olds who identify as transgender or non-binary.

This uncertainty raises the prospect of personal liability for doctors confronted with future lawsuits brought by regretful detransitioners.

In online discussions beginning on November 25, “gender-affirming” GPs (general practitioners in primary care) have complained of mixed messages from Avant on the hot topic of indemnity cover for the practice of “GP-led” hormone prescribing for minors without the precaution of input from a multi-disciplinary team of specialists.

“I wanted to write to you and let you know of my recent decision to detransition… I led myself to believe I was [trans], and my delusion was affirmed. I was seeking a solution for the deep emotional pain and physical discomfort from issues that should have been treated instead of pursuing experimental synthetic hormone ‘therapy’ and irreversible surgical modifications to my body.”—A letter from detransitioner Morgan to her former gender clinician, 3 December 2022

GP guidance

Treatment guidelines issued in 2018 by the Royal Children’s Hospital Melbourne (RCH)—and used by over-subscribed specialist gender clinics in children’s hospitals across Australia—were recently revised with a view to ramping up primary care provision by GPs of cross-sex hormone treatment for adolescents. The revised guidelines fail to acknowledge new studies showing the weakness of the evidence base.

“The research in this area over the past five years has been prolific, yet none of that research has been considered or included in this ‘updated’ document [from RCH],” Brisbane-based clinical psychologist Dr Vanessa Spiller told GCN.

“This is unacceptable and inexplicable. It also means that changes in the guidelines can only reflect ‘professional consensus’, considered the lowest level of evidence.”

“The highly medicalized approach for youth presenting with gender dysphoria has come under scrutiny in the Netherlands. The Netherlands is both the birthplace and the international center of expertise for the practice of youth gender transitions. As of 2023, there is growing Dutch debate in the medical, legal, and cultural contexts regarding the practice of youth gender transitions.”—analysis, Society for Evidence-based Gender Medicine, 19 November 2023

Risky business

In Australia, the medical defence fund MDA National moved first to take account of the exposure signalled by detransitioner litigation.

In July this year, the fund ceased to shield doctors in private practice against claims arising from starting a minor on cross-sex hormones, which carry risks including cardiovascular disease, sterilisation and sexual dysfunction. The legality of a GP alone initiating hormones for a minor is in doubt.

Citing the “high risk of claims”, MDA National said, “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.”

The gender-affirming health lobby originally promoted irreversible hormones for minors as the domain of multidisciplinary specialists, but primary care provision of hormones is increasingly encouraged in order to bypass “gatekeeping”, gender clinic waiting lists and to deliver supposedly “lifesaving” treatment throughout the country at scale.

In August, consistent with the campaign for spreading hormones via suburban doctors’ practices, the Royal Australian College of General Practice endorsed a new special interest group devoted to “Transgender and Gender-Diverse Healthcare” with most of its membership of 160-plus GPs reportedly advocates of the gender-affirming treatment approach.

“Even during the first few years of the clinic, gender medicine was becoming rapidly politicized. Few were raising questions about what the activists—who included medical professionals—were saying. And they were saying remarkable things. They asserted that not only would the feelings of gender distress immediately disappear if young people start to medically transition, but also that all their mental health problems would be alleviated by these interventions. Of course, there is no mechanism by which high doses of hormones resolve autism or any other underlying mental health condition.”—opinion article, pioneering Finnish gender clinician Professor Riittakerttu Kaltiala, The Free Press, 30 October 2023

No clearer

In response to inquiries from GCN last Friday, Avant’s general manager of corporate affairs, Paul Perry, said the insurer’s position had not changed and its indemnity policy “extends to the provision of healthcare for patients identifying as transgender or gender incongruent,” subject to (unexplained) policy terms and conditions.

Mr Perry did not answer the question whether Avant would cover claims arising from GP members initiating opposite-sex hormones for 16- or 17-year-old patients without the backing of a multi-disciplinary team.

In last week’s online discussion about this issue, one practitioner said she had been told in writing by Avant that she would only be covered if she were working with a multi-disciplinary team involving, for example, a paediatric endocrinologist, fertility specialist and sign-off from two psychiatrists. Even then, Avant reportedly advised it would need to consider any claim before it decided whether it would indemnify the GP.

Other doctors said they were simply told they were covered for under-18 gender medicine patients as long as both parents approved; this is in any case a requirement under family law.

GCN understands that Avant is the indemnity fund defending psychiatrist Dr Patrick Toohey in the negligence claim brought by detransitioner Jay Langadinos. This case in its early stages.

Video: The documentary No Way Back: The Reality of Gender-Affirming Care tells a story of risk and regret. (If prompted for a password, use @2022affirmation; the full documentary is here.)

Coverage to worry about

On November 25, The Age and The Sydney Morning Herald ran a high-impact magazine cover story mentioning MDA National’s new caution, parents who feared hormones would harm their children, and two unnamed detransitioners who were either suing or considering suing their medical practitioners.

Two days later, The Age reported a government-funded project in the state of Victoria to train GPs to give hormones from the age of 16 using the “informed consent” model, which elevates patient “autonomy” over safeguards such as a mental health assessment.

The newspaper quoted Queensland University’s emeritus professor of law, Patrick Parkinson, as doubting the legality of GPs “prescribing hormones [to 16- or 17-year-olds] without a formal diagnosis of gender dysphoria and the involvement of an expert multi-disciplinary team”.

He also told The Age that the Family Court, which handles disputes between parents over access to gender medicine for under-18s, had “never approved the use of these [hormone] drugs” for non-binary or gender-diverse people.

In a 2021 article for an online magazine of the Medical Journal of Australia, Professor Parkinson and Dr Philip Morris of the National Association for Practising Psychiatrists set out in more detail what they argued were the remaining constraints on hormones for under-18s.

The article challenged the accuracy of advice in the Australian Journal of General Practice and on the TransHub website of the government-funded trans activist organisation ACON, a former gay rights lobby.

TransHub had claimed, “Any GP is able to prescribe gender-affirming hormonal therapy for most people aged 16 and above, without requiring approval from a mental health professional or endocrinologist.”

The article by Professor Parkinson and Dr Morris cited the Family Court’s famous 2017 re Kelvin ruling as requiring for minors “treatment in accordance with established guidelines. Invariably, these guidelines require the involvement of a multidisciplinary team.”

The RCH gender-affirming clinic had launched the re Kelvin test case and submitted to the court its draft “Australian standards of care” treatment guideline to persuade the judges that medical knowledge of gender dysphoria had advanced such that the court could safely be more selective in its supervision of the treatment decision to start a minor on cross-sex hormones.

The court went along with this partial relaxation of scrutiny, but said—

“Best practice medical treatment for gender dysphoria is offered following a comprehensive multidisciplinary assessment.

“The multidisciplinary treating team may include clinicians with experience in the disciplines of child and adolescent psychiatry, paediatrics, adolescent medicine, paediatric endocrinology, clinical psychology, gynaecology, andrology, fertility counselling and services, speech therapy, general practice and nursing. These treating professionals need to agree on the proposed treatment plan before it can be implemented.

“The existing medico-legal structure for [providing puberty blockers, cross-sex hormones and surgery such as trans mastectomy] in Australia requires at least one psychiatrist or clinical psychologist to confirm a diagnosis of gender dysphoria in adolescents prior to medical intervention.”

Now, however, the new version 1.4 of the RCH treatment guideline appears to introduce an uncertain qualification to the document’s original emphasis on multidisciplinary care.

The document still says, “The optimal model of care for trans and gender-diverse adolescents who present to services involves a co-ordinated, multidisciplinary team approach.”

But the new advice says: “GPs with sufficient expertise and skill in initiating and monitoring [cross-sex] hormone therapy can consider initiating and optimising hormone therapy for [minors competent to consent to treatment].

“This would typically be within a primary care-led multidisciplinary team tailored to the patient’s needs and availability of services…”

It is not explained how GPs will know when they can go ahead without a multi-disciplinary team.

Adding to the confusion, version 1.3 was still available on the RCH website at the time of writing; in that version, there is no recommendation that GPs initiate cross-sex hormones.

Version 1.4 does not cite any new evidence to justify GP-led hormones. RCH has not issued any public statement explaining the reasons for the change and did not reply to GCN’s requests for comment.

A physician sceptical of the gender-affirming treatment model, speaking anonymously to avoid harassment by activists, told GCN that version 1.4 of the RCH guideline “represents a radical shift and substantially reduced standard of care for young people experiencing concerns about their gender identity.”

“The document does not represent the broad views of the wider Australian medical community, [but rather the] ideologically driven aspirations of a tiny minority of medical practitioners who feel that pharmaceutical, surgical and social transition represent gold standard care.”

The physician highlighted the guideline’s new advice that “in some circumstances” a GP might lack the confidence to initiate hormones and should refer the minor to “a qualified mental health professional with experience in providing gender-affirming care”.

This might be read as implying that in most circumstances a GP initiating hormone treatment need not involve assessment by a mental health professional.

“The requirements and standards for mental health care vary widely throughout the [RCH guideline] document,” the physician said.

“The bottom line is that, to have any chance of credibility, RCH’s document must recommend what they think are consistent, reasonable, minimum standards for children and adolescents. Genuine patient care standards should not fluctuate depending on the qualifications of their treating doctor or team.”

Systematically speaking

Since the RCH guideline was issued in 2018, five systematic reviews commissioned by expert public sector health agencies in Finland, Sweden, the United Kingdom (one review each for puberty blockers and cross-sex hormones) and the American state of Florida have found the evidence base for medicalised gender change with minors to be very weak and uncertain.

Systematic reviews, which use a transparent, up-front method to minimise bias and cherry picking of studies, are considered to be at the apex of the evidence hierarchy.

“The [RCH] guidelines claim to be evidence-based, yet they exclude the highest levels of evidence currently available in this field: five systematic reviews that have been conducted independently throughout the world,” clinical psychologist Dr Spiller told GCN.

“In the research world, systematic reviews and meta-analysis are recognised as the highest level of reliable evidence about a particular topic. For an updated ‘Australian standards’ or benchmark document to exclude the highest level of research evidence available is inexcusable.”

She said the guideline also withheld the fact that following those systematic reviews, health authorities in Finland, Sweden, the UK and Florida had decided to restrict routine hormonal treatment in favour of a “therapy first” approach.

“[Also excluded from the guideline is] up-to-date evidence of harms and risks of gender-affirming care for children and young people, including young people with disabilities such as autism,” Dr Spiller said.

“[This guide] recognises that gender dysphoria/incongruence can often be a manifestation of complex pre-existing family, social, psychological or psychiatric conditions or predisposing factors. A holistic approach to assessment includes a comprehensive exploration for these potential conditions in order to more fully understand a child presenting with gender dysphoria/incongruence. Where these conditions are presenting as gender dysphoria/incongruence, the treatment of the underlying condition is a priority.”—Managing Gender Dysphoria/Incongruence in Young People: A Guide for Health Practitioners, National Association of Practising Psychiatrists, Australia, updated 1 December 2023

Anti-affirming?

Version 1.4 of the RCH treatment guideline gives credit for its new GP-hormone advice to a guideline working group of GPs under the umbrella of the Australian Professional Association for Trans Health (AusPATH), which is a hybrid professional-advocacy body.

In The Age and The Sydney Morning Herald newspapers on November 25, AusPATH’s president, Dr Ashleigh Lin, claimed that Europe’s shift to a more cautious stance on gender medicine was the result of influence by an “anti-child and -adolescent-affirming lobby”. No evidence for this claim was presented, and no mention was made of the role of systematic evidence reviews in more cautious treatment policy. Dr Lin, who is also a researcher, did not reply to a request for comment.

AusPATH, which says it opposes exploratory therapy “as a euphemism” for unethical “conversion therapy”, has complained about the “questioning of an affirmative approach” by England’s independent review of gender dysphoria care, led by the distinguished paediatrician Dr Hilary Cass.

It is AusPATH that has reportedly taken control of the project to undertake the first major revision of the RCH guideline following Dr Michelle Telfer stepping down as director of the RCH gender clinic. All four authors of the 2018 guideline are from RCH and the document bears the hospital’s imprimatur.

RCH did not reply when asked if its name and logo would appear on the document once it is updated under AusPATH’s supervision.

In March this year, Professor Gordon Guyatt, a pioneer of the evidence-based movement in medicine, said the RCH guideline was not “trustworthy” because it failed to grade the quality of evidence for its treatment recommendations.

GCN acknowledges that gender-affirming clinicians genuinely believe their interventions help vulnerable youth. GCN sought comment from RCH Melbourne, Dr Lin and the leadership of the RACGP special interest group.