Full steam ahead

Experts put the case for not derailing Australia's first independent review of the evidence for gender medicalisation of minors

Photo by Dekler Ph on Unsplash

The gist

The first Australian state to restrict paediatric gender medicine and propose its own independent review of the evidence should go ahead with its plans despite intervention by the federal government, according to emeritus professor of law Patrick Parkinson and prominent psychiatrist Dr Philip Morris.

On Tuesday, the state of Queensland announced an immediate halt to new prescriptions of puberty blockers and cross-sex hormones for gender-distressed minors in the public health sector, pending a review of the evidence base.

Yesterday, Australia’s federal Health Minister Mark Butler issued a media statement saying he had asked the National Health and Medical Research Council (NHMRC) to devise “new national treatment guidelines” in concert with an expert committee and to carry out a “comprehensive review” of existing guidelines from the Royal Children’s Hospital (RCH) Melbourne.

The RCH Melbourne guidelines, which pioneered the contentious “gender-affirming” treatment approach in Australia, are badged as “Australian standards of care,” have quasi-national status and are used by paediatric gender clinics across the country.¹

However, in tension with Mr Butler’s statement promising new guidelines, his Assistant Health Minister Ged Kearney took to social media to claim that the federal plan was actually an NHMRC “update” of the “excellent” RCH treatment guidelines as requested by gender medicine lobbyists the Australian Professional Association for Trans Health (AusPATH) and activist group Transcend.

Ms Kearney chairs the government’s LGBTIQA+ Health and Wellbeing 10-year National Action Plan Expert Advisory Group, whose members include gender medicine lobbyists, gender clinicians and trans activists.²

At a media conference following his statement, Mr Butler said he had told his Queensland counterpart, Tim Nicholls, that the state should abandon its own evidence review given the involvement of the NHMRC as a guarantor of national consistency.³

Asked about Queensland’s pause in new hormonal treatment, Mr Butler appeared to pre-empt any genuine federal review of the RCH treatment guideline by saying he had stressed to Mr Nicholls “the crucial importance of ensuring that young trans and gender-diverse Queenslanders have access to the best possible comprehensive and appropriate care.”

This presupposes that self-declared trans identity is the key issue affecting distressed children and that the hormonal interventions promoted by the RCH guideline are the most effective and safe therapeutic response.

The centre-left Labor Party is in power federally, while the centre-right Liberal National Party (LNP) governs Queensland, making it the only mainland state not ruled by Labor.

The implications of the NHMRC guideline process for Queensland’s proposed evidence review are unclear.

On Friday night, a spokesman for the Queensland government would only say that, “The safety and wellbeing of Queensland kids has always been our focus and will continue.”

Professor Morris, president of the National Association of Practising Psychiatrists which has published a cautious guide to helping minors with gender distress, said he hoped the Queensland government would stand firm.

Professor Parkinson also said Queensland should proceed with its planned review of the evidence.

“There is a vast gulf between what Minister Butler said the [NHMRC-led] inquiry would do and what his deputy [Ms Kearney] said,” Professor Parkinson told GCN earlier today.

“She claimed the federal inquiry was not a national inquiry at all. Its purpose is just to ‘update’ the existing ‘excellent’ RCH Melbourne guidelines at the request of the activist groups AusPATH and Transcend and in which they will play a significant role.

“How on earth could the community have confidence in that when it is AusPATH’s practices that need review?”

Professor Parkinson, a critic of the medicalised gender-affirming treatment approach, noted that Queensland’s evidence review would take 10 months, whereas the federal project would deliver only interim advice on puberty blockers in mid-2026.

“There is cause for concern, therefore, that the [federal Labor] politicians want to ‘kick this issue into the long grass’ rather than have a genuine, independent and expert inquiry into the research evidence and current practices,” he said.

Professor Morris said the intervention of the NHMRC was no reason for Queensland to give up its plan to review the evidence independently.

“Queensland should go ahead with its own inquiry and hopefully come up with some answers that might be able to help children and their parents deal with these controversial issues in a timely manner,” he said.

Mr Butler did not give a timeline for the full NHMRC guideline process. Australia must have a federal election no later than May 17 this year.

One theory is that Mr Butler’s intervention was calculated to neutralise gender clinic controversy before the election, denying the centre-right leader of the federal Opposition, Peter Dutton, the opportunity to campaign on concern about gender medicalisation of children. Opinion polling has confirmed mainstream apprehension about the irreversible medical transition of minors.

Rejection of radical trans ideology by American voters was reportedly a factor in November’s Republican victory. This week, just before Mr Butler’s announcement, President Trump issued an executive order seeking to restrict paediatric gender medicine.

Update: The NHMRC has announced that its guideline process would take three years. Queensland has confirmed it will go ahead with its own independent review of the evidence base for paediatric gender medicine. February 6, GCN

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Video: Paediatrician Dr Iván Florez on the ingredients of a trustworthy guideline

The detail

The parents’ and clinicians’ group Genspect Australia, which supports non-medical gender interventions, emphasised that “the integrity of any new [NHMRC-led] guideline rests on the appropriate selection of review panel members.”

“It is essential that the experiences of both detransitioners, who have been harmed by gender medicalisation, and parents who advocate for a cautious ‘watchful-waiting’ approach are considered”, said Genspect spokesperson Judith Hunter.

Professor Parkinson said: “The NHMRC is an excellent body capable of doing robust and independent work if it is allowed to do so without being saddled with a politically driven process and membership of its review panel. Even so, it will take years.”

Genspect’s Ms Hunter argued for an immediate nationwide moratorium on new hormonal treatment.

“The UK has already looked at the evidence on puberty blockers and stopped [their routine] prescription,” she said.

“Children are being harmed right now, with treatments that lead to sterility, loss of sexual function, and a myriad of long-term health problems from incontinence to risk of stroke. All states need to follow Queensland with a pause in new prescriptions.”

The LGBTQ lobby group Equality Australia, which has opposed any inquiry into youth gender clinics, said: “Medical experts, health bodies and LGBTIQ+ groups have cautiously welcomed the federal government’s announcement it will review the treatment guidelines for trans and gender-diverse young people.”

Nicky Bath, chief executive of LGBTIQ+ Health Australia, who sits on the government’s LGBTIQA+ health advisory body chaired by Ms Kearney, said: “Gender-affirming care saves lives and nobody wants to see trans and gender-diverse young people unable to access the lifesaving medications that they need.”

There is no good foundation for Ms Bath’s claim, according to multiple independent systematic reviews of the evidence base for hormonal treatment undertaken in jurisdictions as different as Sweden, the UK, Finland and Florida since 2018.

Equality Australia’s chief Anna Brown said Queensland should resume the prescribing of puberty blockers and cross-sex hormones, and she supported Mr Butler’s call for the state’s evidence review to be abandoned.

Debate accelerates

Mr Butler’s intervention on Friday capped a week of dramatic developments.

Aside from Queensland’s moratorium on gender medicine and Mr Trump’s executive order, Australia’s Labor Prime Minister, Anthony Albanese, was sent an open letter urging him to establish an independent national inquiry into paediatric gender medicine, which the letter described as “a potential public health disaster of generational significance.”

Mr Butler sought to decouple his government’s guideline proposal from these developments, saying he had sought advice from the National Health and Medical Research Council (NHMRC) and the Therapeutic Goods Administration “two weeks ago.”

His January 31 statement did not mention the open letter seeking an immediate public inquiry into youth gender clinics.

The case for that inquiry, involving federal-state co-operation, is set out in a January 29 letter to Mr Albanese signed by more than 100 prominent Australians in politics, the law and medicine—including Queensland’s whistleblower child and adolescent psychiatrist Dr Jillian Spencer—as well as detransitioners.⁴

The letter notes the overseas shift away from the medicalised gender-affirming treatment approach, and says “a growing number of detransitioners believe their gender distress masked other co-morbidities, including autism, untreated sexual trauma, and discomfort with their sexuality.”

Former centre-right Liberal prime minister Tony Abbott, who signed the letter, said: “If we don’t let [minors] drink legally, buy cigarettes, vote, or drive a car, why on earth would we allow them to decide on what could amount to chemical sterilisation or surgical mutilation?”

As for Queensland’s initiative, Health Minister Nicholls said on Tuesday that the state evidence review would be wide-ranging, independent and external to the government, with the yet-to-be-appointed lead reviewer consulted on terms of reference.

Mr Nicholls cited three triggers for action—

The “contested evidence” internationally for hormonal treatment of minors with gender distress and the emergence of more cautious treatment policy in countries such as the UK, Finland and Sweden

A whistleblower raising concerns about “unauthorised” treatment at Queensland’s regional Cairns Sexual Health Service

“Criticism” directed at the statewide Queensland Children’s Gender Service (QCGS) and a contentious government-run evaluation of that service last year under the former Labor administration

“We owe it to children to ensure that care is grounded on solid evidence and that we act in this contested area… with caution,” Mr Nicholls said.

He said that in June last year, the public QCGS had 547 children and adolescents “actively receiving care,” not all of them on hormonal treatment. Some 450-500 minors are reportedly on the waiting list now.

QCGS patients already on puberty blockers or cross-sex hormones would continue to get these medications.

Asked on ABC radio about suicide risk, Mr Nicholls said gender-distressed children with mental health co-morbidities would still get psychiatric and psychological support at QCGS.⁵

QCGS appears to have a higher use of puberty blockers per capita than the London-based Tavistock service, which was the world’s largest youth gender clinic; the Tavistock was shut down as a result of England’s landmark 2020-24 Cass review.

Research commissioned by Dr Cass criticised three unnamed Australian gender clinics—one appeared to be QCGS—for using a fast-track to puberty blockers for young children without safety data.

A Cass-commissioned international survey of gender clinics revealed that an unnamed Australian clinic—identifiable as QCGS—said it did not screen new patients for autism because it claimed such screening is “not accurate in [the] trans population.”

Minors with autism, sometimes undiagnosed, are over-represented in gender clinic caseloads and thought to be especially susceptible to gender confusion.

The following comments on Queensland’s treatment pause and proposed evidence review were made before the federal government’s intervention—

Whistleblower psychiatrist Dr Jillian Spencer: “I am very relieved about the decision by the Queensland LNP government to cease new prescriptions of puberty blockers and cross-sex hormones to minors. I’m optimistic that the independent state-wide inquiry into gender services will include a re-evaluation of the [gender-affirming] model of care and will be truly independent and scientific. It is important that they select a strong and courageous person to lead the inquiry.

“One of the most disappointing things I have witnessed over the last two years is the number of senior child psychiatrists who have kept quiet about the harm being done to children from gender-affirming interventions for the sake of preserving their career and avoiding interpersonal conflict. We need to improve the culture of the profession so that we can deal with such challenges within our profession more appropriately.”

Amanda: “My experience as the mother of my autistic daughter who decided to transition to male when she was only 14 years old was like a cyclone. I did not know much about this issue and had previously been very supportive of transgender rights. But as I became embroiled in the world of transgender medicine and transgender politics, I learned quickly that these young people were not being properly assessed nor properly treated with psychological therapy.

“We were told [by the Queensland Children’s Gender Service, QCGS] to get an external therapist, and there was no quality control in terms of seeking outside therapy. My daughter already had a psychologist who did not know about gender dysphoria.

“Inside [QCGS], we were shown a flow chart at the first appointment about the various stages of medical transition. This only fuelled my daughter’s enthusiasm. The medical model was the main one available to us at the clinic. We were told by a [QCGS] doctor that the best treatment for gender dysphoria is to transition. As a psychologist, I was absolutely appalled and shocked that [QCGS] clinicians did not take a meticulous history, that their assessment process seemed full of obvious holes, and yet they were still happy to offer medical interventions.

“In the end, I saved my daughter from the clinicians. I read widely, and I encouraged her to read widely from both sides of the issue and after 18 months, she decided against medical transition and now lives as a gender non-conforming young woman who has fluid sexuality. Like so many of the young people who end up in the system, she did not need to irreversibly change her body. She needed to love herself, accept her neurodivergence and her differences and be OK with all of that.

“Based on my own experience and the experiences I have heard about from many other families, I think a full investigation into the practices of the youth gender clinics is essential.”⁶

Mixed messages

Mr Butler’s January 31 media statement, the key federal government document, focuses on the role of the National Health and Medical Research Centre (NHMRC) in the development of quality guidelines and makes no mention of the involvement of the lobbies AusPATH and Transcend. The statement promised “new national guidelines” and a comprehensive review of the RCH guidelines, not merely an update.

The history of the gender clinic debate raises questions about the timing and purpose of Mr Butler’s intervention.

At his Friday media conference, Mr Butler justified his NHMRC initiative by referring vaguely to new international evidence since the 2018 publication of the RCH guidelines, which would include the systematic reviews ordered by the Cass review and published as peer-reviewed papers.

Mr Butler also invoked the need for “community confidence” in the quality of treatment for children, as well as the fact that the RCH guidelines “have not been approved by the NHMRC.” Both he and Ms Kearney cited the need for “national consistency” in guidelines, without detailing any problem of inconsistent approaches between Australian gender clinics.⁷

Mr Butler denied he was seeking to quash Queensland’s evidence review.

“I’ve given deep consideration to this area over the course of summer, given movements overseas,” he told the media conference.

He said that “some weeks ago”, he had sought advice from the NHMRC and the Therapeutic Goods Administration on paediatric gender care and was told it was “a contested and evolving” field.

Although there is nothing new about the ambiguous status of the RCH guideline, it was raised publicly by Mr Butler for the first time this week, just days after Queensland announced its treatment pause and evidence review.

In multiple documents sent to Mr Butler and Ms Kearney from departmental officials between 2022 and 2024, the RCH treatment guideline was cited as if it were the national standard, and there no was concern expressed about inconsistent treatment approaches across the country, nor about the RCH guideline lacking NHMRC endorsement.⁸

In a November 2022 note on puberty blockers, a senior official said the RCH treatment guidelines “aim to maximise quality and care provision to trans and gender-diverse children and adolescents across Australia.”

In August 2022, the then chief executive of RCH, Bernadette McDonald, forwarded a “helpful” note on England’s Cass review from then gender clinic director Dr Michelle Telfer to Mr Butler’s then department secretary, Professor Brendan Murphy.

Dr Telfer’s note stated that, “Care provision [in Australia] follows our national guidelines, the [RCH] Australian Standards of Care and Treatment Guidelines, which were praised by an editorial in The Lancet in 2018.”

The document trail also undermines Assistant Minister Kearney’s claim yesterday that the RCH guideline is “excellent.”

Last year, just after the April 10 release of the final report from the Cass review, senior officials from Australia’s Department of Health briefed Mr Butler and his deputy Ms Kearney on the historic findings, according to documents obtained under Freedom of Information law.

The ministers were told that the Cass review had found “a lack of robust evidence on the long-term benefits and outcomes of these [puberty blocker] interventions.”

“The Cass review raised concerns about the quality of available clinical guidelines indicating they have not followed international standards for guideline development,” the officials’ briefing note said.

“The review contends [that] of the clinical guidelines reviewed, most performed poorly on ‘rigour of development, applicability and editorial independence domains.’

“This included Australia’s standard, the Melbourne Royal Children’s Hospital’s Australian Standards of Care and Treatment Guidelines for Trans and Gender-diverse Children and Adolescents 2018.”

Back then, Mr Butler took no action.

Why now?

There have been several opportunities for Mr Butler—and his Liberal Party predecessor in the portfolio, Greg Hunt—to address the contested status of the RCH treatment guideline and to involve the NHMRC.

As early as 2019, The Australian newspaper reported—

“The RCH standards document—whose four authors were all from RCH — do not carry the imprimatur of the NHMRC as an endorsed national guideline, a status meant to signal ‘a guideline is of high quality, is based on the best available scientific evidence, and has been developed to rigorous standards’.

“A spokeswoman for the NHMRC said it was ‘theoretically possible’ for an endorsed national guideline to be developed by an expert committee drawn from a single clinic ‘but it would be unusual for the relevant expertise at the required level to be found in one place’.”

In 2020, the Royal Australasian College of Physicians, which had an undeclared track record of promoting gender medicalisation, told the then health minister Hunt—

“While the 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. In these circumstances, guidelines developed using best available evidence and expert clinician consensus are entirely valid.”

In 2021, The Australian reported that the NHMRC had considered the 2018 RCH guideline for inclusion in the council’s online portal of Australian Clinical Practice Guidelines but 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 at the time.

In March 2023, a pioneer of the evidence-based movement in medicine, Professor Gordon Guyatt of Canada’s McMaster University, declared the RCH guideline not “trustworthy.”

He seized on the statement by the RCH guideline authors that, “The scarcity of high-quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations.”

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

Regardless of the volume of evidence, an assessment of the data cited in support of treatment recommendations is considered necessary within evidence-based medicine.

The concession by the RCH authors that high-quality evidence was lacking is found in a version of their guideline published by the Medical Journal of Australia and behind a paywall. It does not appear in the publicly available version on the RCH website.

A higher grade?

A new national guideline developed to NHMRC standards would require a systematic review of the evidence base for treatments such as puberty blockers and cross-sex hormones. And this time, according to Mr Butler, the GRADE system would be used to rate the quality of evidence for treatment advice.

Although the 2018 RCH guideline does not cite an assessed evidence base for its recommendations, an RCH-funded systematic review of the scientific literature on hormonal treatment of young people was published the same year in the journal Pediatrics.

Its authors, among them RCH head of research Dr Ken Pang, reported the discouraging result that the evidence for the psychosocial and cognitive impact of these treatments was “generally lacking.”

This Pediatrics paper, not cited in the RCH guideline, was billed as the first systematic review of hormonal treatment for minors.

Since 2018, systematic reviews in several jurisdictions including Finland, the UK, Sweden, Germany and Florida have confirmed that the evidence base for hormonal treatment of minors with gender distress is very weak and uncertain.

A similar result would be expected if the NHMRC guideline development process using GRADE is independent and competent. Members of the expert committee to shape the guideline have yet to be named.⁹

Assistant Minister Kearney said on Friday that the NHMRC would “consult very closely with the [LGBTQ] community, with organisations like AusPATH and Transcend, people with ‘lived experience’ and clinicians to make sure that the care [that] a very vulnerable part of our community gets is up to date and in line with the most recent scientific evidence.”

The NHMRC was recently party to a joint statement on sex and gender in research which says—“While typically based upon the sex characteristics observed and recorded at birth or infancy, a person’s reported sex can change over the course of their lifetime and may differ from their sex recorded at birth.”

The statement uses gender ideology terms such as “cisgender” and “non-binary.” It says, “Gender identity is about who a person feels themselves to be.”

Together with Mr Butler’s Department of Health and the Medical Research Future Fund, the NHMRC is responsible for multi-million dollar research grants to gender-affirming clinicians, including RCH guideline author Dr Pang.

1. The RCH guidelines promote the chemical disruption of normal puberty, advise high-dose testosterone drugs for teenage girls, and argue that even minors with psychosis can be good candidates for an irreversible medical transition. The guidelines suggest that a double mastectomy at age 16 is routine for a gender-distressed girl. The word “detransitioners” does not appear, nor anything from the scientific literature since 2018. The guidelines claim that puberty blockers afford children “time to develop emotionally and cognitively” before embarking on hormones. In 2022, RCH acknowledged that the effects of puberty suppression on the adolescent brain are unknown.

2. See here for the membership of that advisory group.

3. In his January 31 statement, Mr Butler acknowledged state jurisdiction over health but justified his federal intervention by citing the expert national role of the NHMRC and its “statutory responsibility for developing and supporting high quality guidelines for clinical practice.”

4. A list of signatories is here.

5. It is unclear the extent to which QCGS offers traditional mental health support. Families are referred to the private sector for this support, sources have told GCN. Under the mandatory gender-affirming treatment approach at QCGS, traditional exploratory therapy could be regarded as unethical “conversion therapy.”

6. Amanda is a pseudonym.

7. In Friday’s social media video, Ms Kearney claims the RCH guideline update is “actually in line with” the government’s December 2024 National Action Plan for the Health and Wellbeing of LGBTIQA+ People. There is no reference to gender treatment guidelines in that plan.

8. These documents were obtained by GCN under Freedom of Information law.

9. Gender clinicians have dismissed Dr Cass, a paediatrician, as an “unqualified” reviewer. However, Dr Cass was chosen because she did not have a stake in the field of paediatric gender medicine, which would have given rise to a conflict of interest. Gender clinicians were consulted during her review, but not allowed to dictate.