Mr Butler's puberty blues
It's come to light that Australia's Health Minister was more worried about puberty blockers than we knew
To block or not to block?
Australia’s federal Health Minister Mark Butler sought urgent advice on the case for “a pause or ban” on puberty blockers.
Citing new safety restrictions in the UK, Mr Butler’s office asked health bureaucrats last December for a briefing on “the weight of evidence in support of a pause or ban in the Australian context,” according to documents obtained under Freedom of Information (FOI) law.
The revelation implies a level of concern behind the scenes not reflected in Mr Butler’s generally reassuring public commentary on youth gender clinics as a matter under the competent control of state governments and health practitioners.
The FOI material also sets the scene for the federal minister’s unexpected intervention on January 31, when he declared he had asked the National Health and Medical Research Council (NHMRC) to develop new national treatment guidelines to ensure public confidence in healthcare for vulnerable young people with gender distress.
On that day Mr Butler, from the centre-left Labor Party, gave a media conference at which he sought to pressure the conservative-run state of Queensland into abandoning its own recently announced review of the evidence for puberty blockers.
Mr Butler also made comments that appeared at least sceptical of Queensland’s precautionary decision on January 28 to suspend any new gender treatment with blockers in public health.
In that politically charged episode, it was not public knowledge that the federal health minister himself had sought advice on possible restrictions of these drugs.
Mr Butler requested this “urgent” briefing from the Department of Health and Aged Care on December 13, the day after news that his UK Labour counterpart, Wes Streeting, announced an indefinite ban on private prescribing of puberty blockers for gender-distressed children.
“The Cass review made it clear that there is not enough evidence about the long-term effects of using puberty blockers to treat gender incongruence to know whether they are safe or beneficial,” Mr Streeting told the UK House of Commons in remarks reported on December 12 last year.
“That evidence should have been established before they were ever prescribed for that purpose. It is a scandal that medicine was given to vulnerable young children, without proof that it was safe or effective, or that it had gone through the rigorous safeguards of a clinical trial.”
The December 13 request for departmental advice from Mr Butler’s office noted that the UK decision was made “on safety grounds” and asked Australian health officials to cover issues including—
“The evidence around the safety of current Australian practice
“The weight of evidence in support of a pause or ban in the Australian context
“If the minister [Mr Butler] wanted to commission a review of the evidence and/or clinical guidelines in Australia, the recommended scope and approach for such a review, or another alternative approach to examining the prescribing practices in all Australian jurisdictions
“With regards to the matters above, the potential impacts on the mental health and wellbeing of young Australians, international experience, and the findings of Australian reviews”
“Concern has been raised about the unknown or potentially harmful effects of suppressing normally timed puberty on adolescent physical and mental health, especially with regard to bone mineralization and brain development”—Treatment for Pediatric Gender Dysphoria, a review of evidence and best practice commissioned by the US Department of Health and Human Services, 1 May 2025
“Hormonal interventions can lead to infertility and impaired sexual function, and in some cases, if the patient proceeds to genital procedures, riskier operations.
“In the past five years, a growing body of research and peer-reviewed literature has examined the phenomena of detransition and regret. Personal accounts from detransitioned patients who report having been harmed by [paediatric medical transition] have played a significant role in drawing public and regulatory attention to these issues.”
Their problem, not ours
The Australian officials’ briefs sent to Mr Butler on December 17-19 last year do not explicitly address the case for a pause or ban on puberty blockers, although they imply that the UK restrictions are not relevant because of the following claims—
The NHS service delivery model is “largely centralised,” whereas Australia’s is distributed between the states1
The “unacceptable safety risk” with puberty blockers cited by the UK Commission on Human Medicines relates to “the UK prescribing context, rather than a specific safety concern related to particular medicines used in the gender-affirmation process”2
Dr Cass saw the clinical decision-making of the NHS as “binary,” involving a choice between a medical pathway or “ignoring other options,” whereas gender care in Australia is multidisciplinary3
Puberty blockers are reversible and give minors “time to develop emotionally and cognitively before making decisions on gender-affirming hormone use that have some irreversible effects,” according to the de facto national treatment guideline issued in 2018 by the Royal Children’s Hospital (RCH) Melbourne4
Australia’s Therapeutic Goods Administration (TGA) is “not aware of any regulatory action being considered for off-label use of GnRH analogues [puberty blockers] … in gender-affirming hormone therapy”5
A 2024 report in New Zealand found “a lack of quality evidence to back effectiveness and safety of puberty blockers,” although the government response was not a ban but a statement that “a more cautionary approach” was needed6
“Puberty suppression is reversible and typically relieves distress for trans and gender-diverse adolescents by halting progression of physical changes such as breast growth and menstruation in trans males and voice deepening and facial hair development in trans females,” according to the 2017 treatment guideline of the Endocrine Society7
The 2024 Sax review in the state of New South Wales (NSW) had declared puberty blockers to be safe and reversible, while an evaluation of the children’s gender clinic in Queensland had found it to be “safe, evidence-based and consistent with national and international guidelines”
Missing data
The December 17-19 briefing documents for Mr Butler do not mention the fact that the NSW Sax review exaggerated the quality of the evidence for youth gender clinics by misusing the rating tool of the NHMRC. Nor do the documents note published critiques of both the Sax review and the Queensland clinic evaluation.
The positive findings of those two state government-commissioned reviews are at odds with multiple systematic reviews of the evidence internationally; Mr Butler was not briefed on these systematic reviews, which carry more weight.
Undertaken independently in Finland, Florida, Sweden, the UK and Germany, all of these systematic reviews have found the evidence for puberty blockers to be very weak and uncertain, meaning there is no firm basis for claims by gender clinicians that these drugs confer mental health benefits.
But the December 17 brief for Mr Butler did offer him options for federal intervention in the state-based field of youth gender clinics.
He was advised that the federal government “can play a role in providing national leadership (e.g. clinical guidelines, informational resources for patients and health professionals) and consistency of a best practices approach.”
Mr Butler may have been presented with other options in this brief; six paragraphs under the heading “Considerations for Australia’s approach to puberty blockers” were blanked out by the department’s FOI officer on the grounds that this material would reveal “thinking processes” of government.8
Thought led to action the following month, when Mr Butler gave the NHMRC the job of developing “new national guidelines” for youth gender dysphoria.
The NHMRC is to use the international GRADE system to rate the quality of the available evidence for treatment recommendations.
The RCH Melbourne gender clinic failed to assess the level and quality of evidence for the clinical advice in its 2018 “Australian standards of care” guideline, pleading the lack of high-quality research data. This failure led McMaster University’s Professor Gordon Guyatt, a pioneer of evidence-based medicine and the GRADE system, to judge the RCH guideline “untrustworthy.”
See the Inquirer section in tomorrow’s Weekend Australian newspaper (May 3-4) for an article raising serious questions about how gender-affirming care became routine and standard in Australia
GCN acknowledges that gender-affirming clinicians believe their interventions benefit vulnerable young people
NHS England’s national gender clinic, the now closed Tavistock service, is being replaced with distributed clinics embedded in mainstream healthcare, but there is no suggestion that this change should allow a return to routine use of puberty blockers in public health.
This misses the point. The recommendation of the UK Commission on Human Medicines, like Mr Streeting’s decision to act upon it, flowed from Dr Cass’s work and associated systematic reviews of the internationally shared evidence base for puberty blockers. And the Cass review did in fact give rise to specific concern about blockers as a medicine used in “gender affirmation.”
As NHS England explained in March 2024, “We have concluded that there is not enough evidence to support the safety or clinical effectiveness of [puberty blockers] to make the treatment routinely available at this time.” Mr Streeting’s January 11 statement to parliament also contradicts the narrow view presented to Mr Butler by his officials.
The “UK prescribing context” behind the ban on private provision appears to mean the existence of the GenderGP online clinic, which claimed it had a legal way to prescribe puberty blockers for British children denied routine access to the drugs by the NHS.
GenderGP has said it follows the 2018 treatment guideline of the Royal Children’s Hospital (RCH) Melbourne. This document is the de facto national standard in Australia. In a 2020 podcast, GenderGP co-founder Dr Helen Webberley told RCH gender clinic director Dr Michelle Telfer that she was “envious” of her “beautiful guidelines.”
The UK stand-alone Tavistock gender clinic also claimed to take a multidisciplinary approach. The testimony of US detransitioners suggests that true holistic care is incompatible with the ideological “gender-affirming” treatment approach. The “specialist team” rhetoric of the gender-affirming clinics in Australian children’s hospitals is at odds with the blockers-only reality as found by Family Court judge Andrew Strum in the recent case re Devin.
The RCH Melbourne gender clinic no longer makes the unqualified claim that puberty blockers are reversible; its website now says they are “largely reversible,” without explanation. The “time to think” rationale for puberty blockers has been undermined by international data showing that the vast majority of children begun on these drugs progress to cross-sex hormones.
The RCH clinic has belatedly acknowledged to patients that the effects of puberty blockers on the still developing adolescent brain are unknown and has launched a research project on this topic.
Up until last year, Mr Butler’s officials presented RCH Melbourne’s treatment guideline as the de facto national standard. In January this year Mr Butler shifted position, noting that the RCH guideline had “not been approved by the NHMRC.”
The reporting of adverse events with a medication such as puberty blockers is voluntary for doctors, although pharmaceutical companies must notify the TGA of serious adverse events. The database of adverse event notifications is here.
The NZ Ministry of Health’s idea of more cautious policy was advice that prescribing be limited to clinicians experienced in “gender-affirming care”—the treatment model responsible for promoting puberty blockers as safe, beneficial and reversible, without any solid evidence base.
The trustworthiness of that guideline was challenged after a British Medical Journal investigation involving a pioneer of evidence-based medicine, McMaster University’s Professor Gordon Guyatt, who found “serious problems” with the Endocrine Society document.
For example, the society commissioned systematic reviews of the evidence to support its guideline but did not consider the effect of puberty blockers or cross-sex hormones on gender dysphoria itself, which Professor Guyatt said was arguably “the most important outcome.”
GCN has lodged an FOI appeal against the removal of this material.
Another great article, Bernard! It feels like people might be on the verge of waking up to the harms of the gender affirming model, which for so long we haven't been allowed to question.
I wish the politicians didn't rely so heavily on captured institutions, especially those who stand to benefit financially, for policy advice.
Perhaps, in the near future our paediatric hospitals might have to cast aside this unethical woke nonsense and get back to treating sick children?