The hoax of 'holistic' gender medicine
A clinician says Australia's gender medicine lobby should put patients first and heed the warnings of England's Cass report
Urgent concerns raised by the UK Cass report have been roundly dismissed by Australian gender clinicians. After almost four years of work, Dr Cass’s report reflects a meticulous analysis of all relevant international research including systematic reviews of the weak evidence base for treatment of gender-distressed young people. Yet the best response that gender clinicians in Australia can muster is an eerily identical chorus that “Australia is not the UK” and a hollow refrain that gender dysphoria management is “complex and evolving.” The acknowledgement of this uncertainty does not appear to cause restraint or circumspection as gender clinicians continue to initiate radical hormonal regimes in children; regimes which are, by design, required for the remainder of the child’s life.
Gender clinicians are eager to reassure the Australian public that international research is not relevant to their practice. Somehow, the echoed reassurance of “multidisciplinary teams” is supposed to assuage mounting concerns by Australian doctors, young people, parents, journalists, politicians, academics and the legal profession. This emphasis on multidisciplinary care is tactical. The public is not being told that Australia’s general practitioner doctors (GPs in primary care) are increasingly starting lifelong cross-sex hormones for 16- to 17-year-olds independently of specialists such as endocrinologists or psychiatrists. These GPs are celebrated by the Royal Australian College of General Practitioners as a “Special Interest Group”.
What Australia’s gender clinicians have not done is respond, in any way, to the specific concerns raised by the Cass report, much of which is directly applicable to unacceptable practice in Australia. It is arguable that Australian gender clinics have some of the most egregious examples of substandard care and malpractice in the world. This is why parents and detransitioners, burdened with regret about past medical interventions recommended by trusted clinicians, are starting to bring claims to court.
Simply claiming that Australia’s “gender-affirming care” is holistic doesn’t make it true. Even if a patient’s history is carefully noted and a multidisciplinary team is involved, it falls short of holistic care when a gender clinic offers only a narrow pathway of hormonal intervention. Genuine holistic care would mean best practice management of all relevant conditions, not just the gender distress presented as the key problem.
Do Australia’s health ministers know the clinical reality that lies behind the slogan of “holistic gender-affirming care”? Consider the case of Maple Leaf House, a gender clinic in NSW’s Hunter region which takes young people under the age of 25. This clinic has a growing reputation for internal staff problems, hauling the reluctant parent in a family before a court to force treatment of the child, and allowing ideological presuppositions to override clinical discretion.
On the surface, Maple Leaf House can be viewed as a success, with 986 young people seen in the past year, more than 12 full-time staff and a very large number of patients initiated on puberty blockers and “gender-affirming” hormones. While 91 otherwise pubescent children were receiving puberty blockers as at September 24 last year, Maple Leaf House is understood to have refused to report the number of young people prescribed cross-sex hormone treatments, despite clear Freedom of Information requests.
Clinicians in the Hunter region have noted that Maple Leaf House fails to engage with the complexities present in a young person’s life. Serious medical and mental health issues are documented in letters from referring doctors, but then ignored or dismissed by Maple Leaf House as unrelated to gender distress or inexplicably unimportant. Issues such as autism spectrum disorder, attention-deficit/hyperactivity disorder, major depression, anxiety, a history of sexual violence, other childhood trauma and family issues appear to go unaddressed by Maple Leaf House, despite their staff including a paediatrician, child and adolescent psychiatrist, endocrinologist and social worker.
At least one well-regarded gender-affirmative clinician has quit reportedly as a result of the insistence at Maple Leaf House that young people start treatment even when serious concerns remain about their suitability. Clinicians in the Hunter are concerned that this same ideological model is likely to be deployed in the NSW government’s planned South-East Sydney Metropolitan Gender Hub.
Video: Australia’s Senator Claire Chandler on the local relevance of last month’s decision by England’s National Health Service to restrict puberty blockers to clinical trials
Proper care, not shortcuts
Our young people deserve thorough assessment and genuine holistic care. The predetermined outcomes of the gender-affirming treatment model have no place in medicine. Serious mental health issues, neurodiversity and trauma should be given priority, not overlooked in favour of simplistic hormonal regimes.
Young people with gender distress should be offered careful identity exploration; sometimes psychological and psychiatric care will be needed. Shortcuts should not be excused by misleading use of the term “informed consent”, which in gender medicine means fast-track approval of hormones without the safeguard of a mandatory mental health assessment. Clinicians should work with, not against, the family. Loved ones should never be legally threatened or confronted with coercive and false threats. The “transition or suicide” narrative has been shown to lack foundation in evidence.
The problematic stand-alone clinic of Maple Leaf House and its empty promise of multidisciplinary care should serve as a cautionary tale for the rest of the country. Less than three years after the clinic opened, evidence of patient harm is already mounting but is likely to grow exponentially in the coming decade. It calls into question the lack of protections intrinsic to the gender-affirming model and the post-Cass tactic of invoking the term “multidisciplinary” as if that guarantees safe, effective and evidence-based care.
The management of clinics caring for young people should be based on the best available systematic reviews of the evidence base, such as those commissioned by Dr Cass and independently undertaken in Sweden and Finland. These reviews show the evidence for hormonal treatment of gender-distressed minors to be very weak and uncertain. This is why new, more cautious treatment policy in England, Sweden and Finland has concluded that puberty blockers should be restricted to clinical trials. The Cass report advises against routine use of cross-sex hormones for minors.
Yet Australia’s gender clinics still assert that hormonal interventions are settled science and the uniform recommendation of experts. The widely proclaimed consensus exists only among those who are ideological wedded to the gender-affirming treatment model. This small international group of practitioners is characterised by controversial clinical practices and an alarming uniformity of public comment. Their circular referencing of one another’s treatment guidelines and talking points has been described as a “citation cartel”. Clinical management should never be at the whim of ideologically self-referential guidelines that conceal the lack of high-quality evidence for gender-affirming medical interventions.
Most Australian medical practitioners would strongly disagree with the gender-affirming approach but are reluctant to speak publicly against its practices because of a toxic activist culture which derides genuine concerns and rejects well-founded critiques (like those of the Cass report) as irrelevant, “transphobic” or as promoting unethical “conversion therapy”.
Sober-minded clinicians cannot support the dysphoria treatment guidelines issued by the gender clinic of the Royal Children’s Hospital Melbourne and promoted as “Australian standards of care”. This document is littered with preposterous suggestions such as advising that lifelong hormonal treatment may be started in an actively psychotic child. It is remarkable that health ministers, hospital managers and otherwise careful clinicians have placed such faith in these irresponsible guidelines. The Australian medical community, parents and children deserve robust healthcare anchored in evidence, eager to improve clinical practices and learn from thoughtful recommendations based on the highest quality international research.
The Cass report and its concerns have direct relevance to Australia. Our children’s hospital gender clinics and other community-based gender clinicians should be subject to independent ethical oversight and safeguards for child wellbeing. The prescription of puberty blockers or cross-sex hormones for young people should only occur with complete transparency in a supervised, ethical and methodologically sound clinical trial. Such trials should have regular independent reviews of each young person’s wellbeing, their response to the intervention, any adverse effects and their ongoing suitability to continue with treatment.
Australia has trusted gender clinicians with thousands of our children. We need to return to normal medical principles of thorough assessment, evidence-based medicine, the avoidance of harm, recognition of gaps in knowledge and openness to scrutiny and correction. To hide behind gender-affirming terminology, or to insinuate that without hormonal intervention young people might refuse to go to school, engage in self harm or commit suicide is irresponsible, manipulative and untrue.
Young people with gender and identity concerns deserve the very best of care. At present, evidence-based care is not available despite generous public funding for Australia’s gender clinics. Intoning the mantra that “Australia is not the UK” is an excuse to continue to expose children to the risks of experimental treatment; it betrays the lack of a credible rejoinder to the considered findings of Dr Cass. Australian kids deserve care that is just as good as in the UK. If our country’s gender medicine was as excellent and holistic as is proclaimed, it would have nothing to fear by learning from thoughtful international colleagues. Surely only clinics with indefensible, unbalanced care would shy away from the best available evidence.
The author is an Australian clinician writing anonymously in order to speak honestly without becoming a target for activist smears.
HOLISTIC defined as:
Characterized by the belief that the parts of something are interconnected and can be explained only by reference to the whole.
The term is often used in the fringes of medicine, the naturopaths, homeopaths, iridologists and the like.
What is required in gender medicine is EVIDENCE, something sadly lacking in the ‘affirmative model’ of managing gender dysphoria.
Gordon Guyatt, distinguished Professor of ‘Health Research Methods, Evidence, and Impact’ at McMaster University in Hamilton, Ontario is the guy who coined the term ‘evidence base’.
He’s no slouch when it comes to insight into what’s OK and what’s not when it comes to ‘dicey’ medical interventions.
He nails the those who argue that the affirmative model for addressing gender dysphoria is somehow evidence based: "When there's been a rigorous systematic review of the evidence and the bottom line is 'we don't know,'" he says, then "anybody who then claims they do know is not being evidence based."
The dogged commitment to this approach by its defenders despite its obvious and cruel harms to children ( and vulnerable adults ) is so inexplicable that it makes me doubt their sanity. And the reflexive retort that the Cass report has no relevance to Australian children - apparently accepted as the end of the matter as far as various health ministers are concerned - is bizarre. What is wrong with these people?