Forbidden
If medical treatments for minors lack a sound evidence base, wouldn't an inquiry prevent rather than inflict harm?
Australia’s federal Health Minister Mark Butler has rejected the first state government-level request for a national review of medicalised gender change for minors.
The federal minister dismissed the proposal, put to him on May 31 by the state of Tasmania’s Health Minister Guy Barnett, with Mr Butler relying on discredited 2020 advice from a medical college that reportedly suppressed expert concerns about the poorly evidenced hormonal treatment of gender-distressed children.
Mr Butler did not make his response public. GCN obtained a copy of his letter to Mr Barnett under Freedom of Information law.
The Butler reply, sent on June 25, says: “Regarding your call for a national review, I note that in 2020 the Royal Australasian College of Physicians (RACP) developed advice on the treatment of gender dysphoria.
“The advice was informed by consultation with relevant clinical experts and noted that a national inquiry would not increase the scientific evidence available regarding gender dysphoria but would further harm vulnerable patients and their families.”
The RACP gave no evidence for its claim that the “increased media and public attention” of an inquiry would be harmful, nor did it discuss any of the potential harm inflicted on minors by puberty blockers, cross-sex hormones or transgender surgery such as double mastectomy.
In June, Tasmania’s Minister Barnett announced that he had written to Mr Butler suggesting a national review, arguing it was “highly important” that public gender services for children and adolescents had “rigorous patient safety and clinical governance measures in place.”
He was the first Australian health minister to call for a local inquiry after England’s Cass review, the world’s most comprehensive study of how best to respond to the surge in gender-distressed youth, handed down its final report in April.
“[G]iven the Cass review was undertaken at a national level in the UK, it is preferable that a review of public gender services [in Australia] be undertaken by the Commonwealth [the federal government],” Mr Barnett told the feminist group Women Speak Tasmania, which had been campaigning for an inquiry into paediatric gender transition in that island state.
“A survey of 15 international gender clinics, commissioned by England’s Cass review, highlights the fact that three Australian clinics offer a ‘unique’ pathway for ‘peri-pubertal’ children who are given priority on the waiting list for psychological support and access to puberty blockers when eligible. This pathway means Australian minors may stay on puberty blockers longer or start cross-sex hormones earlier, with no good data to predict safety or beneficial outcomes, according to the peer-reviewed paper reporting the 2022-23 survey.”—GCN, news post, 29 April 2024
Suppression
Last year, journalist Natasha Robinson revealed in The Australian newspaper that although the 2019-20 RACP review did consult the Endocrine Society of Australia, that society’s serious reservations about paediatric gender medicine were suppressed.
The Royal Children’s Hospital (RCH) Melbourne was central to the RACP review because its gender clinic had spearheaded the contentious “gender-affirming” approach in Australia and issued the 2018 “Australian Standards of Care” treatment guidelines for dysphoria used across the country by children’s hospitals.
The then director of the RCH Melbourne clinic, paediatrician Dr Michelle Telfer, was also first author of the 2018 treatment guidelines and a fellow of the RACP.
In a confidential letter to the RACP review in 2019, an external expert consulted by Australia’s Endocrine Society said: “The RCH approach claims to set Australian Standards, but the document represents solely the attitudes of one group of advocates in one institution.”
“There are gaps in the evidence that the RCH document does not adequately address, one instance being the statement that [hormone suppression drugs prescribed off-label] to block puberty progression are reversible.”1
But the concerns of the Endocrine Society, representing Australia’s experts on hormones, were not included in the four-page RACP advice sent in March 2020 to the then federal Health Minister Greg Hunt, who had asked the college to co-ordinate the review following critical coverage of gender medicine and the RCH Melbourne clinic in The Australian.
After the RACP advice was made public, it emerged that the college had a track record of lobbying for minors to be given faster and less costly access to the hormonal treatments it was later asked to evaluate.
The college had campaigned for puberty blockers to be subsidised by taxpayers, for an end to judicial supervision of treatment decisions involving minors2 and for an $8 million project to create an RCH-style gender-affirming network of clinics in the state of New South Wales.
The 2020 RACP advice to Minister Hunt did not disclose any conflicts of interest.3
Sub-standard
In his letter in June this year rejecting the Tasmanian request for a federal review, Australia’s federal Health Minister Butler makes no reference to the national interest arising from the fact that the RCH “Australian Standards of Care,” used nationwide, have recently been found to be of low quality and not fit for use after a peer-reviewed evaluation of international guidelines.
Mr Butler’s own officials have briefed him on the result of that evaluation, which was undertaken as part of England’s landmark Cass review. Like Australia’s “gender-affirming” medicine lobby, Mr Butler has suggested the Cass review lacks local relevance and requires no change Down Under.
Mr Butler has also been told by his officials that the Australian Health Practitioner Regulation Agency would use the RCH Australian standards when judging any formal complaints against health professionals over the treatment of young people with gender distress.
“You may be interested in a full debrief of my meeting with Dr Hilary Cass from the UK who was able to provide valuable insights into their process there.”—New Zealand’s Chief Medical Officer, Dr Joe Bourne, from a cache of internal emails as the NZ Ministry of Health works on its long-delayed “evidence brief” on puberty blockers, 20 May 2024
Ill advised
The 2020 RACP advice did not name or describe the treatments at the centre of international debate—puberty blockers, cross-sex hormones and surgery such as double mastectomy.4
The college claimed, without citing any studies, that minors with gender dysphoria had “extremely high rates of depression, self-harm, attempted suicide and suicide.”5
It sought to explain the “limited” evidence for medicalised gender change by comparing the distress of gender dysphoria to “rare cancers.”
The RACP advice cited no studies nor any data, and said nothing of the exponential increase internationally in the number of young people—atypically teenage females—identifying as trans or non-binary and seeking medical intervention.
It sought to explain away the failure of the 2018 RCH Melbourne “Australian Standards of Care” to follow guideline development standards set to underpin quality.
“While the National Health and Medical Research Council (NHMRC) guideline development process is often considered ‘gold standard’, we note that for health issues which are lower in prevalence and where the evidence base is still developing, following the NHMRC guideline development process in its entirety may not be feasible,” the RACP advice says.6
“In these circumstances, guidelines developed using best available evidence and expert clinician consensus are entirely valid.”
The RACP advice went on to highlight only those guidelines recommending the gender-affirming approach.
These included international guidelines found not to be evidence-based after a 2023 investigation in the British Medical Journal.
The RCH Melbourne guideline has been judged “untrustworthy” by a pioneer of evidence-based medicine Professor Gordon Guyatt of Canada’s McMaster University.
Since the RACP argument that an inquiry would not add to the scientific evidence, there have been multiple systematic reviews—the gold standard for evidence—showing that gender medicalisation of minors rests on very poor and uncertain data.
GCN put questions to Mr Butler, Mr Barnett and the RACP.
The Endocrine Society’s Medical Affairs Committee told the RACP: “This is a complex area, the evidence base is limited and the RCH [treatment guideline] document largely reflects the authors’ opinion because, as the authors themselves state, ‘the [scarcity of high-quality] published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations’.” The Endocrine Society’s external reviewer said: “RCH advocacy for an affirmative model is, in effect, accepting a child’s wishes as unassailable and implies that any parental reluctance to accept the diagnosis of gender dysphoria and its treatment is ill-informed resistance to be overcome by goal-oriented ‘counselling.’ The RCH argument that non-treatment in the face of gender dysphoria is not neutral, uses an exaggerated risk of suicidality to make this unbalanced argument seem necessary.”
In 2015, the RACP issued a media release featuring paediatrician Dr Telfer’s argument for removal of Family Court supervision of access to medical interventions for minors. She explained the surge in gender dysphoria cases as the result of a more tolerant society and “transgender celebrities coming out and sharing their stories.” “When you have people such as Bruce Jenner coming forward, more media attention means the longer the waiting list for our gender service gets. The rising awareness and the recognition of the transgender population in the context of equality is one of the most rapidly progressing areas of social change in our time. To catch up with this social progression, we must recognise the urgency to educate medical professionals, to develop and provide comprehensive medical services as well as changing the legal system to one which does not discriminate.”
Minister Hunt gave The Age first access to the 2020 RACP advice and his spokesman issued a statement to the newspaper: “In recognition of the risks of further harm to young people, the government does not intend to establish a national inquiry on this matter.” Not long after this, when I had a chance to talk to Mr Hunt, I asked him whether or not he believed an inquiry would cause harm. He sought to disown the claim, suggesting it had been added by officials without his knowledge.
In July last year, RACP president Dr Jacqueline Small appeared to disown the March 2020 advice to Mr Hunt. In correspondence with a concerned doctor, Dr Small played down the significance of the advice, noting it “did not comment on specific clinical issues such as the use of puberty blockers and other treatments.” Dr Small said the RACP was “not intending to develop clinical guidelines or position statements on the treatment of gender dysphoria.”
In her 2020-24 review, Dr Cass found no evidence supporting the “transition or suicide” narrative. She cited recent research suggesting that the suicide risk in gender clinic patients is driven by their often serious mental health problems, not gender distress itself.
In 2021, I reported in The Australian newspaper that the NHMRC had considered the RCH Melbourne treatment guideline for inclusion in its online portal Australian Clinical Practice Guidelines but found it did not qualify. “At the screening stage it was determined that the [RCH] 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.
“Australia’s federal Health Minister Mark Butler has rejected the first state government-level request for a national review of medicalised gender change for minors”.
It is worthwhile understanding the qualifications that Mark Butler might have in order for him to be able to grasp complex medical issues as they might impact on their wellbeing
All federal politicians have their ‘Qualifications and occupation before entering Federal Parliament’ referenced on the parliament website, herewith Mark Butlers:
• LLB(Hons) (University of Adelaide).
• MIR (Deakin University).
• BA(Juris) (University of Adelaide).
• Union official from 1992 to 2007
The only proper job Mark Butler ever had was a Union Official for fifteen years.
Go Figure!