Gender clinic under review

But is this an investigation designed to fail?

Photo by Delia Giandeini on Unsplash

A review of the gender clinic in the Australian state of Queensland has begun.

Senior health officials have described the evaluation of the Queensland Children’s Hospital clinic—which gives puberty blockers, cross-sex hormones and has a policy that enables surgery in the private sector—as “independent”.

However, the review may involve nothing more than checking the clinic’s “gender-affirming” operations for compliance with the (contentious) gender-affirming treatment guideline issued in 2018 by the Royal Children’s Hospital Melbourne (RCH) and promoted as “Australian standards of care”.

At a December 12 meeting, consultant physicians at the Queensland Children’s Hospital were told that the Brisbane-based gender clinic would be evaluated against the benchmark of the RCH treatment guideline.

The gender-affirming treatment approach enshrined in the RCH guideline regards even very young children as “experts” in transgender or non-binary “gender identities” untethered from birth sex, and it claims that puberty blocker drugs, cross-sex hormone treatment and surgeries, such as mastectomy or the creation of an artificial vagina, are “lifesaving”.

The December 12 meeting was also told the review would be headed by a senior government health official, psychiatrist Dr John Allan. He is executive director of the Mental Health Alcohol and Other Drugs Branch of the government department Queensland Health. Dr Allan’s branch has a role in the “enhancement of safe, quality, evidence-based clinical and non-clinical services”.

GCN put questions about the nature and limitations of the review to Children’s Health Queensland, which runs the hospital, and the office of Health Minister Shannon Fentiman, but there was no reply.

Child and adolescent psychiatrist Dr Jillian Spencer and paediatrician Dr Dylan Wilson—prominent Queensland clinicians who have led calls for an independent inquiry and raised concerns about the safety and evidence base of the gender-affirming treatment approach—expressed scepticism about the value of the government’s review.

“The problem is actually with the [RCH] ‘Australian standards’,” said Dr Spencer, adding that she doubted a review constrained in this way would be able to “identify all the serious problems besetting” the Queensland gender clinic.

“When clinics are guided by the ‘Australian standards’, parents don’t have a chance of getting what they want—comprehensive care for their child which won’t set their child up for lifelong problems like infertility, lack of sexual function, the dangers of surgery, complex physical health problems and a lifetime of medication reliance,” Dr Spencer told GCN.

Systematic reviews undertaken independently in Finland, Sweden, England and the American state of Florida since 2019 have found the evidence base for puberty blockers and cross-sex hormones to be weak, uncertain and of low quality. This has led to new, more cautious policies favouring non-invasive psychological interventions as first-line treatments. The systematic reviews have undermined the familiar claim that gender clinic medical interventions are “lifesaving”.

“The RCH standards of care are not based on a systematic review of the evidence, and they advocate for an affirmative model of care despite the lack of evidence and the unknown safety of this treatment approach,” Dr Spencer said.

“We need the inquiry to take a step back from the RCH standards of care, which is a very flawed document, and strive for higher standards of care for the Queensland gender clinic to protect the health and well-being of Queensland children.”

The RCH standards were recently updated to encourage more family doctors—known as general practitioners or GPs—to start 16- and 17-year-olds on irreversible “gender-affirming” hormone drugs. The RCH update ignored the post-2019 systematic reviews of the evidence base.

Dr Spencer said it was unclear how a restricted Queensland review could take into account the international shift to greater caution in gender dysphoria care and all possible therapeutic responses to young people who present with gender distress.

Dr Wilson said an effective inquiry should be modelled on England’s independent review of youth gender dysphoria care led by paediatrician Dr Hilary Cass, which drew on 2021 systematic evidence reviews carried out by the UK’s National Institute for Health and Care Excellence.

“Gender clinicians [in Australia] should welcome an independent review, because if they’re practising appropriately, without concerns, then the review will vindicate that practice,” Dr Wilson told GCN.

He said an independent inquiry should be—

External to Queensland Health in order to have the freedom to criticise, if found necessary;

Empowered to obtain all information, public and private, on the treatment of children;

Led by a reviewer senior and experienced enough to appraise evidence and not be swayed by ideology;

Not led by someone already committed to the gender-affirming treatment model.

At the time of writing, Queensland’s health authorities had made no public statement about the review, although the controversy at the gender clinic has received national and international publicity via September’s 7NEWS Spotlight program “De-Transitioning.”

“At the current rate I will have to pay $129 per month in hormones for the rest of my life (60 years), and on top of this cover all the medical expenses caused by my messed up endocrine system and post-surgical complications. I have become a profitable medical experiment.”—Detransitioner “Sam”, tweet, 18 December 2023

“In the past, [conversion therapy of homosexuals] took the form of electroshock therapy, chemical castration and even lobotomy. Now it takes the form of rendering teenagers sterile and sexually dysfunctional for life. Clinicians from the main UK transgender service [the Tavistock clinic] referred to prescribing puberty blockers as ‘transing the gay away’—a play on the description of old-fashioned conversion-therapy as ‘praying the gay away’.”—Endocrinologist Dr Roy Eappen (who, as he put it, happens to be gay) of the watchdog group Do No Harm, opinion article, The Wall Street Journal, 14 December 2023

Child-led treatment

Earlier this year, Dr Spencer was suspended from clinical duties at the Queensland Children’s Hospital following a patient complaint of “transphobia” and after her frustrated attempts to raise concerns about patient safety and a hospital-wide insistence on use of the poorly evidenced gender-affirming treatment approach.

The founder of the Queensland gender clinic, Dr Stephen Stathis, has acknowledged before an audience of fellow psychiatrists that the evidence for the gender-affirming model is of low quality. He told them he no longer believed that puberty blockers offer children a “pause” to consider the next step to lifelong hormones. The RCH guideline promotes puberty blockers as “reversible”.

In Queensland’s parliament last month, Health Minister Fentiman conceded the lack of consensus on the treatment of youth gender dysphoria in the course of her reply to a question about the evidence to support the gender clinic’s medical treatments.

Ms Fentiman retained her portfolio in yesterday’s cabinet reshuffle supposed to improve the long-serving Labor government’s chances as it approaches difficult state elections in October next year; it is behind in opinion polls.

“There is still some uncertainty about the safety and effects of the treatment of children with gender dysphoria. In some countries, this is reason to argue for great restraint. This lack of clarity is seen by medical experts in the Netherlands as an important but acceptable risk, taking into account that denying care to a large group of transgender young people is also harmful to mental health.”—Dr Ernst Kuipers, Health Minister for the Netherlands (which was the pioneer of puberty blockers and paediatric transition), answers to questions arising from the Zembla documentary “The Transgender Protocol”, 13 December 2023

In his response, [Dr Kuipers] ignores the growing group of leading scientists who fundamentally criticise scientific research into the treatment of underage transgender people. [Dr] Kuipers states that Zembla spoke to ‘a limited number of experts’, but this does not do justice to the scope of the criticism and stature of the critics. For example, he says nothing about the four Dutch academic methodologists who stated to Zembla that the scientific evidence for the Dutch Protocol [for paediatric transition] is insufficient to serve as a basis for irreversible medical interventions.”—Zembla current affairs program, reply to the minister’s comments, 15 December 2023

But what kind of review?

In a letter to Dr Spencer earlier this year, Queensland’s chief psychiatrist Dr John Reilly referred to plans for Children’s Health Queensland (CHQ)—the government agency responsible for the children’s hospital and its gender clinic—“to conduct an independent review such as you are requesting.”

However, he said he was not aware of the “specific scope for such a review.”

The reviewer appointed, Dr Allan, was president of the Royal Australian and New Zealand College of Psychiatrists from 2019 to 2021.

He was in charge in September 2019 when, following The Australian newspaper’s critical media coverage of the rigour and safety of the RCH treatment guideline, the college quietly cut its explicit endorsement of that guideline from its LGBTQ mental health policy.

In reply to The Australian’s questions about this unannounced change, the college said it had removed the endorsement pending review of the evidence supporting the guideline’s treatment recommendations—and noted that Dr Allan had agreed with the decision.

The college has since produced more cautious policy on gender dysphoria care and has studiedly refused to embrace the gender-affirming worldview to the exclusion of other approaches including psychotherapy. The current 2023 policy notes the trend in Europe to restrict access to puberty blockers following systematic reviews of the evidence base.

“The gender-affirmative model validates and reinforces what adolescents are learning on TikTok. It is now taught in schools as fact that all human beings have an innate ‘gender identity’ and that this is the criteria for being a boy or a girl, not biological sex. There is no scientific basis for this claim. The result of the politicisation of this group of children has been the medicalisation of gender non-conformity. The costs are permanent unwanted physical changes and worsened physical and mental health. The effects of treatment include infertility, anorgasmia, sexual pain, surgical complications, and osteoporosis. The testimonies of those who regret their medical transition (detransitioners) are heartbreaking.”—Stephanie Davies-Arai, founder of Transgender Trend, presentation at the Global Population Health Summit, 26 November 2023

Why punish her?

Paediatrician Dr Wilson said that if the Queensland review were given the independence and freedom to properly scrutinise the work of the gender clinic and found concerns similar to those raised by Dr Spencer, this would pose the question why she was being punished for doing so.

But Dr Wilson told GCN he could see no point in a review limited to the question whether or not a gender-affirming clinic was following the gender-affirming approach as set out in a gender-affirming treatment guideline.

“Why isn’t the Queensland Children’s Hospital [gender clinic] being compared to practices in Sweden or Finland? Why doesn’t the review look and see what the difference is? What are the actual goals of the affirmation pathway [as still followed in Australia]? What are we treating? What are we trying to achieve?” he said.

Dr Wilson said the RCH treatment guideline—with all four authors from the RCH gender clinic—had been self-promoted as “Australian standards” but had no such official status.

“The so-called ‘Australian standards’ are not a standard to be held to. They’re just one descriptor of the affirmation model. They don’t set the bar for good treatment. Even the ‘Australian standards’ themselves say the evidence for certain treatment options is low.

“There are other recommendations and other guidelines available in Australia, such as the [document from] the National Association of Practising Psychiatrists.”

The RCH document and other gender-affirming treatment guidelines cited by Ms Fentiman as supporting the gender clinic’s work have been criticised by leading figures in evidence-based medicine.

The RCH guideline did not qualify for inclusion in the Australian clinical practice guideline maintained by the National Health and Medical Research Council (NHMRC).

“At the screening stage, it was determined that the 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,” an NHMRC spokeswoman told The Australian in 2021.

GCN acknowledges that gender-affirming clinicians believe their interventions are helpful for vulnerable youth.