Risky business

Gender doctors in Australia face an uneasy waiting period as new treatment guidance is developed

Photo by Bernd 📷 Dittrich on Unsplash

Australian Health Minister Mark Butler’s intervention in the field of youth gender dysphoria may lead to increased medico-legal risk for children’s hospitals and doctors involved in paediatric medical transition.

On January 31 this year, Mr Butler undermined the de facto national status of treatment guidelines issued by the Royal Children’s Hospital (RCH) Melbourne, when he announced that the National Health and Medical Research Council (NHMRC) would subject those guidelines to a “comprehensive review,” and develop a new set of evidence-based national guidelines.

At a media conference that day, the federal Health Minister told journalists it was “important to point out that those [RCH Melbourne] guidelines have not been approved by the NHMRC.”¹

The 2018 RCH guidelines introduced and entrenched in Australia a radical form of the “gender-affirming” treatment approach for gender dysphoria in minors, recommending child-led social transition, early puberty blockers, cross-sex hormones with no minimum age, and (in undefined cases) double mastectomies.

Although the guidelines were badged as “Australian Standards of Care,” all four published authors were from a single source: the RCH gender clinic in Melbourne.² Until Mr Butler’s review, the guidelines were treated as if they were the national standard by health authorities.

MDA National, which was the first Australian medical indemnity firm to restrict cover for private doctors engaged in gender transition of minors, has updated its position statement to include Mr Butler’s intervention.

In its update, MDA National notes that Mr Butler’s national guideline review followed advice from the NHMRC, and the indemnity insurer goes on to say—

“Our policy considers the ongoing lack of consensus around the guidelines for a recognised model of care for the treatment of gender transition in patients under 18 years of age, which increases the likelihood of a medico-legal claim against practitioners.

“Further, with regard to patients under 18, the courts are likely to allow claims for many years after the statutes would normally allow, even with the consent of the parent(s) and/or the Family Court.”

A doctor fighting a medical negligence claim may invoke a guideline to help make out a defence that the treatment in question follows “a widely accepted, competent practice,” according to senior legal counsel Bill Madden of Carroll & O’Dea.

Mr Madden, a specialist in personal injury litigation, said the existence of a treatment guideline was useful but not essential for this defence, which was available in most jurisdictions.³

He said that although the Health Minister had set in train a review process, the RCH Melbourne guideline was at this point widely—even if not universally—accepted across Australia, and therefore could assist in a doctor’s defence against a claim.

However, he said state children’s hospitals and gender clinicians would be expected to review their own reliance on the RCH guideline if its treatment recommendations were contradicted by new guidance from the NHMRC; that agency is expected to complete interim advice on puberty blockers by mid-2026.⁴

“And in those circumstances, a [plaintiff] lawyer might be able to turn around and argue that [the treatment] is no longer widely accepted, competent professional practice,” he told GCN.

“According to the [RCH Melbourne] guidelines, medical transition is, in turn, facilitated by the prescription of puberty blockers and cross-sex hormones. Despite arguments that puberty blockers simply ‘pause’ puberty, they are most often a step towards cross-sex hormone treatment that will irreversibly change a child’s physical features.”—Child and adolescent psychiatrist Dr Catherine Llewellyn, opinion article, ABC Religion & Ethics, 21 May 2025—

“Although children are promised an opportunity to ‘change sex,’ the reality is potentially life-long medicalisation.

“Vulnerable Australian youth deserve sensitive, good quality, evidence-based guidelines. I do not believe the [RCH guidelines have] been written to a sufficient standard that should guide the profession in this complex area of healthcare. In future, ‘Australian Standards’ should be a protected title only to be used with reference to governmentally endorsed documents produced to the highest standard.”

Towards clarity

GCN also put questions about the Butler guideline initiative to medical indemnity firms Avant, MIPS and MIGA. The first two said they had made no change in their position or coverage of paediatric medical transition, while MIGA did not reply.

Owen Bradfield, chief medical officer of MIPS, said completion of the NHMRC guideline project should clarify the field; the new guidelines are not expected to be finalised and issued until March 2028.

“The development of national guidelines endorsed by the NHMRC would create clarity for practitioners in this area,” Dr Bradfield told GCN.

“Practitioners who follow those guidelines would have a stronger defence to any claim or complaint arising from gender treatment.

“Of course, it could also expose those who don’t follow the guidelines without clinical justification or a second clinical opinion. It’s hard to be too specific at this stage without seeing the content of those guidelines.”

“[UK] Health Secretary Wes Streeting is ‘actively reviewing’ banning or restricting the private prescription of cross-sex hormones to young people, according to evidence given to the [English] High Court. Government lawyers say an expert panel will report in July on the use of this type of medication by under 18s wishing to change their gender.”—BBC, news report, 22 May 2025

Don’t do it

Meanwhile, the Australian Doctors Federation has issued a medico-legal update on the risks of gender medicalisation of minors, given the weak evidence base and “proven medical harms”.

The federation highlights the fact that the RCH treatment guideline rated poorly in a peer-reviewed evaluation of gender dysphoria guidelines commissioned by England’s Cass review, and was judged “untrustworthy” by McMaster University’s Professor Gordon Guyatt, a pioneer in the field of evidence-based medicine.

“We are concerned about the harms being done to children and the medico-legal risk to doctors,” the federation says.

“To protect yourself [as doctors] we would advise that for children and adolescents up to 18 years of age, you [should]—

“not prescribe puberty blockers and cross-sex hormones;

“not refer for gender surgery;

“not refer to gender clinics as they offer treatment that is not evidence-based and causes bodily harm; and

“not refer patients on for private gender-affirmative psychological treatment that will cement a child’s likely transient identity.”

The federation—which is a small organisation compared with the main doctors’ lobby, the Australian Medical Association (AMA)—suggests its members should contact their medical colleges to request they follow the results of international evidence reviews and recommend the banning of paediatric medical transition.⁵

1. Mr Butler’s then deputy, Assistant Health Minister Ged Kearney, made comments on social media presenting the NHMRC project as merely an update of the “excellent” RCH Melbourne guidelines—an update requested by gender medicine lobby groups.

However, the NHMRC declined to endorse that framing when asked by GCN, and its website echoes Mr Butler’s formula of a comprehensive review of the RCH guideline and the development of new guidelines. The composition of the expert group to lead guideline development is yet to be announced.

2. The full title of the RCH guideline is “Australian Standards of Care and Treatment Guidelines for trans and gender-diverse children and adolescents.” It was issued in 2018 and although it is now badged as Version 1.4 (2023), its reference list has not been updated and cites no studies since 2018.

3. Mr Madden said the rationale for the defence was to avoid drawing unqualified judges into medical assessment of treatment options. He said the defence, in theory, could be defeated by arguing that a widely used medical practice was “irrational,” but there was scant case law to suggest such an argument would succeed.

The availability of the “widely accepted practice” defence meant that plaintiff lawyers were more likely to focus on challenging the correctness of a diagnosis of gender dysphoria, he said.

4. The RCH guideline claims that, “Puberty suppression typically relieves distress for trans adolescents … and is reversible in its effects. Other physical changes such as linear growth and weight gain continue to occur whilst on these medications and the adolescent is given time to develop emotionally and cognitively prior to making decisions on gender-affirming hormone use, which [has] some irreversible effects.” However, the guideline does not rate the quality of the evidence for such claims.

Mr Butler has pointed out that for its new guidelines, the NHMRC will use the internationally recognised GRADE system to assess evidence quality. Multiple systematic reviews of the evidence internationally have found the evidence for the use of puberty blockers (as recommended by RCH) to be very weak and uncertain. RCH itself has acknowledged since the issue of its guideline that the effects of puberty blockers on the adolescent brain are unknown.

5. The AMA has adopted an LGBTQIASB+ Health Position Statement showing the influence of gender ideology and identity politics. The statement offers an uncritical endorsement of the gender-affirming treatment model, cites the RCH guideline, and gives no hint of the very weak and uncertain evidence base for puberty blockers.

The new gender dysphoria report issued by the US Department of Health and Human Services (HHS) devotes a chapter to the capture of medical associations by small numbers of gender-affirming activists relying on low-quality standards of care issued by the World Professional Association for Transgender Health, itself a hybrid medical-activist group.

The HHS report says: “The implicit social contract underlying [the] self-regulatory privileges [of major medical and mental health associations] rests on the expectation that these organizations will prioritize the best interests of patients and society. However, [the] handling of issues related to pediatric medical transition [by these associations] illustrates how institutional biases, reliance on external guidance from advocacy-oriented groups, and internal political dynamics can undermine their regulatory effectiveness and scientific credibility.” (See Chapter 12, pp201-208.)