What Butler knows

Australia's Health Minister has been quietly told that, yes, the Cass report is relevant Down Under

Photo by Amanda Dalbjörn on Unsplash

Australia’s Health Minister, Mark Butler, has been warned by his own department that England’s landmark Cass review found puberty blockers did not improve mental health and that the treatment guidelines used by gender clinics across Australia have been rated poorly for rigour.

These warnings—following the minister’s request for urgent advice the day after the April 10 release of the Cass report—undermine Mr Butler’s public suggestions that Dr Cass’s findings are not relevant to Australia’s gender clinics because of “different care pathways”. The departmental advice also challenges the reassuring claim that Australia’s “multidisciplinary” approach is an effective safeguard.

Australia’s multidisciplinary assessment and its pathway to social transition, puberty blockers, cross-sex hormones and transgender surgery, are set out in the 2018 “Australian Standards of Care and Treatment Guidelines” issued by the Royal Children’s Hospital (RCH) Melbourne.

These guidelines are used by clinics following the “gender-affirming” model in state children’s hospitals across Australia and by the fast-growing stand-alone youth service, Maple Leaf House, in the regional city of Newcastle.

In the five-page advice sent to Mr Butler on April 16—and obtained by GCN under freedom of information law— the federal Department of Health reports that the RCH treatment document is among the majority of gender dysphoria guidelines around the world rated poorly by the Cass review for their lack of rigorous development and independence.

“The Cass review raised concerns about the quality of available clinical guidelines indicating they have not followed international standards for guideline development,” says the ministerial advice cleared by senior official Tiali Goodchild from the population health division of Mr Butler’s department, with the contact officer being Belinda Roberts from the health equity branch.

The Cass report says: “Despite the agreement within the international guidelines on the need for a multidisciplinary team, and some commonalities between them in the areas explored during the assessment process, the most striking problem is the lack of any consensus on the purpose of the assessment process.”

“Any model of care, multidisciplinary included, that follows an affirmation paradigm is destined to fail and therefore harm patients. Individually skilled practitioners are unmatched against the affirmation paradigm, because the paradigm itself only has one direction, one outcome built in. All that the multidisciplinary team can then do is universally affirm and then remove, or never include, those who express any caution or safeguarding concerns.”—US gender clinic whistleblower Jamie Reed, comment to GCN, 29 April 2024

Missing evidence

The departmental advice to Minister Butler notes that the Cass review was set up to examine the “quality of research data¹ and analysis underpinning current approaches to gender-affirming care”—that being the model followed by many clinics internationally, Australia included.

The Roberts-Goodchild advice warns Minister Butler of the “lack of robust evidence on the long-term benefits and outcomes” of using puberty blocker drugs to suppress the natural development of children as young as age 9-10. The advice also notes that blockers have not been shown to improve “gender dysphoria, body dissatisfaction or mental wellbeing.”

The Cass report, the ministerial advice says, “found no clear evidence on the positive or negative mental health outcomes of social transition”—an intervention which the RCH treatment guidelines say “should be led by the child” but which, according to some clinicians, increases the risk that children will go on to lifelong medicalisation.

“The Cass review contends [that] the focus on puberty blockers to manage gender-related distress has overshadowed consideration of the effectiveness of other psychosocial and therapeutic interventions,” the advice to Mr Butler says.

The hormonal treatments prescribed at Australia’s gender clinics are the same as those given at the London-based NHS Tavistock service and other gender-affirming paediatric clinics around the world. Deriving from the original “Dutch protocol” for “juvenile transsexuals”, these medical interventions rely on the same evidence base.

Mr Butler, who in August 2023 had met the gender medicine lobby group LGBTIQ+ Health Australia and asked them for data on puberty blocker use², does not appear to have made any media comments since the Cass report telling the public that his department has alerted him to the weak evidence base for gender clinics. His office did not reply to GCN’s request for comment.

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Relevant or not? An exchange during an Australian Senate estimates hearing, 5 June 2024

One Nation Party Senator Malcolm Roberts: “Are you aware of the Cass report in the United Kingdom?”

Dr Liz Develin, senior official in the Department of Health: “Yes.”

Senator Roberts: “It caused a complete rethink of gender dysphoria in favour of counselling as a first response rather than permanently changing a child’s body. Are there any plans to review the childhood gender care data and childhood gender care in Australia?”

Dr Develin: “I think it’s important to understand that the context of the Cass review, compared to the Australian environment provided by the states and territories, is quite different. My understanding of what the states and territories provide is multidisciplinary care to ensure that there’s a range of health professionals making those decisions.”

Less pharma

April’s departmental brief for Minister Butler notes that the Cass report recommends a more balanced approach to treatment “with greater emphasis on using psychosocial interventions—not to change a person’s perception of who they are but [to] explore their experience of distress and help alleviate this.”

“The review raises concerns about the broader impacts of transition regret and risk of social isolation.”

The departmental advice also alerts the minister to the concern that gender medicine has been allowed to operate with standards of evidence and safety lower than in mainstream medicine, and that the gender bias of the trans-affirmative model may obscure other non-gender conditions in need of treatment, such as autism³, psychiatric disorders or trauma after abuse.

“[The Cass report] recommended that gender services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors,” the advice says.

The advice incorrectly told the minister that, “For those undertaking gender-affirming surgery [in Australia], they must be over 16 years for top surgery [mastectomy] and over 18 years for bottom [or genital] surgery.”

In fact, as the department clarified this week when releasing the document to GCN, there is no minimum age for trans surgery. The likely source of this error⁴ remains uncorrected on the website healthdirect.gov.au, which has also misled journalists.

The Roberts-Goodchild advice did furnish the minister with the line quoted in media coverage—“In Australia, the care pathways are different [than in the UK]”—playing down the local implications of the Cass review. It also provided the other common “no relevance” line that England’s NHS is centralised, whereas Australia has multidisciplinary clinics in various states and territories⁵.

Although the Cass-commissioned evaluation of the RCH treatment guidelines did not recommend their use, the advice to Mr Butler says they are “widely considered the standard” in Australia.

The advice notes that the treatment recommendations of RCH are “based on available evidence including clinical consensus.”

The peer-reviewed version of the guidelines, published by The Medical Journal of Australia, says: “The scarcity of high-quality published evidence on the topic [of youth gender dysphoria] prohibited the assessment of level (and quality) of evidence for these recommendations.”

That statement led a pioneer of evidence-based medicine, Professor Gordon Guyatt of Canada’s McMaster University, to declare the RCH guidelines “untrustworthy”.

The Roberts-Goodchild advice to Minister Butler says the RCH guidelines “provide a detailed outline of the roles of each member of the multidisciplinary team, for example, mental health professionals, paediatricians, adolescent physicians or endocrinologists, GPs [general practitioners or primary care doctors], nurses and bioethicists and some allied health professionals.”

However, the advice does not pick up last year’s unannounced change to the guidelines, which now encourage GPs “with sufficient expertise and skill in initiating and monitoring [cross-sex] hormone therapy” to consider starting teenagers on this lifelong treatment without multidisciplinary back up.

It’s not clear in what circumstances a GP could wisely or legally initiate hormones without specialist support. No new research was cited by RCH to justify this relaxation; the most recent studies referenced by the guidelines are from 2018.

“To the extent they have acknowledged [the Cass report] at all, the gender-affirming advocates who run Australia’s public youth gender services have tried to discredit its methods and argued that its recommendations do not apply to Australia. The true intent of these criticisms of Cass [is] revealed in the fact that these advocates also reject calls for a high-quality Australian review. Clearly these critics are more interested in avoiding scrutiny than they are in an honest evaluation of the practice of gender medicine in Australia. The tragedy is that the abandonment of the core medical principle of basing treatment on rigorous assessment and high-quality evidence will ensure that gender-confused children in Australia will continue to be harmed by practices being banned elsewhere.”—psychiatrist Andrew Amos, opinion article, Eureka Street, 14 June 2024

Personal medicine

The RCH guideline insists on a diagnosis of gender dysphoria by an experienced mental health clinician before hormonal treatment⁶.

However, in 2019, the document’s lead author, RCH gender clinic director Michelle Telfer gave evidence to a royal commission into mental health, saying—

“… it’s really interesting when we think about mental health clinicians within the context of trans and gender-diverse children, because you don’t really need someone to diagnose a person with gender dysphoria, because a trans identity is something that’s so innately personal that really only that young person or adult, depending on what time of their life they’re coming in, only they know how they feel about their gender and whether that’s a problem or not for them.

“… what’s really important to note as well, is that it’s not just the mental health clinicians within our team that are there to support mental health, because for trans and gender-diverse children it’s actually the medical interventions as well as some surgical interventions that help their mental health (Emphasis added—GCN).

“So, for young people, they often say, ‘I don’t need to talk about this anymore, I just actually need to transition’, or for someone who might be 12 or 13, ‘My emerging puberty is causing me so much distress’, that the only way to manage that distress and the consequences that come from that distress is actually to have the physical interventions from the paediatricians with puberty blockers.”

Dr Telfer told the commission that “many” of the “post-pubertal trans males [teenage girls]” who arrived as new patients at the clinic in 2018 “were requesting gender-affirming surgical services in the form of chest reconstructive surgery [double mastectomy].”

Low-quality benchmark

In the event of a complaint arising from a child prescribed puberty blockers, the benchmark for deciding any intervention by the Medical Board of Australia would be the RCH guidelines, according to a departmental brief sent to Minister Butler in May 2023.

The latest brief to the minister from April this year may also be significant for what it does not say. It notes that in advice given to former Health Minister Greg Hunt in 2020, the Royal Australasian College of Physicians (RACP) “expressed support for the principles underlying these [RCH] guidelines and their emphasis of a holistic, multi-disciplinary person-centred care approach”.

Unlike previous briefs to Mr Butler, this latest departmental advice does not highlight the RACP’s unsupported claim that a national inquiry into gender clinics “would further harm vulnerable patients and their families.”

No data, sorry

In a June 2023 Senate estimates hearing, the then secretary of the department, Brendan Murphy, was asked by National Party Senator Matt Canavan about the “remarkable” growth in patient numbers at the RCH Melbourne gender clinic. The context was the inability of federal officials to supply any data on puberty blocker use.

Professor Murphy said he shared “concerns about the capacity of children to make decisions in this matter.”

“But we have sought assurances from [RCH] that they have a very robust process where there are psychiatrists and psychologists and social workers. Their assessments go over many months. I’m assured that the board and the governance of the children’s hospital and the Victorian Health Department continue to review that program,” he said.

In August the year before, Professor Murphy had received an email from RCH chief executive Bernadette McDonald, forwarding to him what she thought might be a “helpful” document written by the then gender clinic director, Dr Telfer.

This document, obtained recently under freedom of information law, ran to a little more than two pages and was titled, “Examination of the Cass review and considerations of implications for the RCH Gender Service.”

The interim report of the Cass review had been published in February 2022 and the London-based Tavistock gender clinic had been marked for closure following concerns about the influence of an ideological gender-affirming model, rushed administration of puberty blockers, possible confusion of same-sex attraction and trans identity, and clinical neglect of non-gender conditions such as autism.

In her analysis sent to Professor Murphy, Dr Telfer said—

“Predictably, the conservative press and anti-trans groups have celebrated the recommendation of closure of the Tavistock. This has been widely reported on internationally. It has also led to a rise in anti-trans activity via social media and other communication forums, directed at trans people themselves, their families and clinicians who provide care for them. The reporting by these media outlets does not reflect the reality of Dr Cass’s report and is extremely harmful to the trans community.”

She claimed her Melbourne gender clinic “already meets the criteria that Dr Cass has recommended to be implemented in England.”

“The RCH Gender Service, with a well-established, multidisciplinary, integrated and collaborative clinical service with community, educational and research programs embedded across the model, is ideally placed to continue to lead this field internationally.”

Dr Telfer said the Tavistock model was “outdated” because it required all adolescents seeking cross-sex hormones to begin with puberty blockers. The RCH guidelines, with Dr Telfer as first author, did away with minimum ages and advised a start to hormone suppression early in puberty at Tanner stage 2-3.

In her letter sent to Professor Murphy, Dr Telfer included her clinic’s nurse-run intake process in a list of what she claimed were Cass-compliant features.

However, this fast-track towards puberty blockers for very young children—similar fast-tracks are used by paediatric gender clinics in Perth and Brisbane—was criticised for pushing beyond the evidence base by Dr Cass’s final report in April this year and in Cass-commissioned research by the University of York.

“The impact of this [fast-track pathway], which might entail longer use of interventions to suppress puberty or earlier commencement of masculinising/feminising hormones, remains unknown as early studies of outcomes of interventions to suppress puberty mandated a minimum age of 12,” the York researchers said.

And while puberty blockers remain routine treatment in Australian gender clinics, they have been confined to clinical trials in England in line with the Cass report’s concern about the lack of safety data and uncertainty surrounding their very rationale.

In April 2022, Dr Telfer—with gender clinic research lead Dr Ken Pang and trans activist Jeremy Wiggins—had argued that Dr Cass’s interim report should have given the green light for routine treatment with puberty blockers to continue, notwithstanding a finding that the evidence was of “very low certainty”.

In the British Medical Journal, the three Australian authors said gender clinics giving children puberty blocker drugs and cross-sex hormones could not wait for long-term data on the safety of these interventions.

“It will take many years to obtain these [undoubtedly needed] long-term data,” the article said.

The Australians argued there was enough existing evidence and international agreement among gender-affirming clinicians to continue these medical treatments aimed at stopping unwanted puberty, then mimicking opposite-sex development.

According to the final Cass report, however, the “apparent consensus” in favour of the gender-affirming model is an artefact of a circular pattern of referencing among various low-quality treatment guidelines, the RCH document included.

GCN sought comment from Mr Butler, RCH Melbourne and Dr Telfer. GCN does not dispute that gender-affirming clinicians believe their interventions benefit vulnerable young people

1. The advice to the minister does not mention the post-2019 independent systematic reviews of the evidence base in Finland, Sweden and the UK, including two reviews by the National Institute for Health and Care Excellence undertaken as part of the Cass review.

2. Mr Butler’s meeting with LGBTIQ+ Health Australia—which sits on a healthcare advisory group chaired by Assistant Health Minister Ged Kearney—followed a June 2023 Senate estimates hearing in which his departmental secretary, Professor Brendan Murphy, was asked questions about puberty blocker usage and oversight. These hormone suppression drugs are used off-label with gender dysphoria. They are approved for other conditions such as prostate cancer and precocious (or premature) puberty.

3. The Queensland Children’s Hospital gender clinic told the Cass review that it did not screen new patients for autism because such screening was “not accurate in [the] trans population.”

4. GCN alerted Healthdirect to errors in April. Family law does not set a minimum age for any kind of trans surgery, as long as parents and doctors aren’t in disagreement. It’s not uncommon for activists to claim that no surgery takes place under the age of 18. In Australia, girls as young as 15 have been referred for trans mastectomies.

5. It’s not explained how multi-disciplinary assessment overcomes a weak and uncertain evidence base.

6. A 10-year audit of the RCH gender clinic reported that 29 per cent of patients aged 10 or older received puberty blockers, while 38 per cent of those minors aged 16-17 received cross-sex hormones. However, the period covered (2007-16) is unlikely to be representative. It mostly predates the boom years of the clinic. From 2007-2013, there were less than 100 new referrals. In 2013, the Family Court liberalised access to blockers, and the judges did the same for hormones in 2017. In 2015, the clinic was given $6 million in extra funding, partly to pay for puberty blockers. From 2014-2022, there were 3,284 new referrals at the clinic.