When there's no why
Panic buying of puberty blockers and an official review that fails to ask the hard questions
Comment
Almost half the children on hormone suppression in an audit at Australia’s second largest public gender clinic had already been prescribed puberty blockers in the private health sector.
This is revealed as a passing remark in a government-commissioned report following a review of the Queensland Children’s Gender Service against the benchmark of the “Australian standards of care” treatment guidelines which assume that puberty blockers1 will be given within the safeguard of a multidisciplinary team.
The audit tracked only 93 patients who arrived in 2023—the year when the Brisbane-based clinic had a total of 899 minors under care—and reported that “45 per cent” of the 11 patients who ended up on government-funded hormone suppression had been reassessed for this intervention after having “commenced on puberty blockers elsewhere (privately)”. The report says nothing about who in the private sector might be doing this prescribing.
“This [private prescribing] is a shocking discovery that is glossed over in the [Queensland government’s] evaluation report. It shows that a proportion of children are starting puberty blockers in the community before being seen by the gender clinic. This practice of prescribing puberty blockers outside of a multidisciplinary team is even in breach of the activist-clinician written “Australian standards of care.”—Queensland child and adolescent psychiatrist Dr Jillian Spencer, comment to GCN, 22 July 2024
State of suppression
Last year, 172 minors were put on hormone suppression at Brisbane’s public clinic. If the patient audit carried out by the government-appointed review panel is representative, there could be an additional 70-80 Queensland families2 willing to pay around $1000 every three months for privately prescribed puberty blockers in circumstances where the quality and safety of assessment are uncertain.
In the state of Queensland, over the six years from 2018 to 2023, at least 703 minors3 were started on puberty blockers at the Brisbane clinic, according to data released under Freedom of Information law. Over a decade or so, in England, the national Tavistock gender clinic based in London gave puberty blockers to an estimated 2,000 minors before it was shut down.
So, per capita, there has been more intensive use of puberty blockers in a single Australia state than throughout England. Roughly three minors per 100,000 population were on blockers in England, compared with about 14 per 100,000 people in Queensland over a shorter period.
In their report, the Brisbane clinic review panel led by psychiatrist Dr John Allan4 states that it “found no evidence of children, adolescents or their families being hurried or coerced into making decisions about medical intervention.”
But the report shows no curiosity about the pressure for treatment applied by young people themselves, their families and transgender advocacy groups. It recognises that, as is the case internationally, the number of minors seeking gender care has “increased significantly” but, again, shows no curiosity about why. And yet the pressure of “consumer demand”—the opaque term used by the panel—pervades the 88-page report.
The questionnaires given to an undisclosed number of “consumers” and clinicians fail to probe for the influence on trans identity of peer groups and social media, or for the possibility that gender distress is a mask for underlying issues such as autism, awkward same-sex attraction, abuse or trauma.5
Video: The new UK Prime Minister, Keir Starmer, stands firm in defence of England’s cautious Cass review of gender medicine in the face of pressure from his own Labour Party colleagues, including the question-asking MP Nadia Whittome, to lift a ban on any prescribing of puberty blockers outside a possible clinical trial—watch from the 2:22 minute mark
But, why?
A psychologist who took her gender-confused daughter to the Brisbane clinic but successfully resisted her medicalisation told GCN: “One of the things that shocked me immensely at [the clinic] was their lack of curiosity about the significant and rapid rise in presentations of gender dysphoria, as well as their lack of curiosity about the very high proportion of young people with gender dysphoria who also had neurodivergence [such as Autism Spectrum Disorder or ADHD]—like my ASD daughter.”
“When I asked about this [at the clinic], they had absolutely nothing for me. I can remember thinking after that—these clinicians are going to offer my daughter and other young people ways to permanently mess with their precious and healthy bodies.
“I was baffled and horrified that they offered nothing by way of good psychotherapy. It was very different to the experience I expected.”
Panic buying
In 2022, a transgender parent group in the far north of Queensland spread word of a crowd-funder campaign to pay for “lifesaving” puberty blockers, claiming that, “For those with gender dysphoria, the onset of puberty is a traumatic and life-threatening event—the time our transgender children are most vulnerable to self-harm and risk of suicide.”
And now, Queensland’s Labor Minister for Health, Shannon Fentiman, has welcomed the Allan report as justifying an extra $2.6 million for the Brisbane clinic to develop a state-wide network, recruiting a new expanded class of doctors with gender specialist credentials. All within the contentious “gender-affirming” treatment approach, meaning more puberty blockers, cross-sex hormones and girls referred to private surgeons for double mastectomies.6
“We know that the care provided at the Queensland Children’s Gender Service is life changing, and, in many cases, lifesaving,” Ms Fentiman said in a media release. Nothing in the Allan report supports the claim that medicalised gender change prevents suicide.
“Health authorities in various western countries have reviewed the medical evidence and concluded that the use of puberty blockers as part of gender transition in minors is experimental… Here in Queensland, child psychiatrist Dr Jillian Spencer says, ‘Why on earth are puberty blockers still being prescribed [at the Brisbane clinic]? Puberty blockers have been in use for at least 20 years and there still isn’t any reliable evidence that they improve psychosocial outcomes. However, there is growing evidence of their harms’.
“Likewise, Queensland paediatrician Dr Dylan Wilson says, ‘Sterilising children and leaving them sexually dysfunctional for the rest of their lives, on the basis of their declared identity, is a medical scandal’.
“We should listen to these doctors and these [European gender medicine] inquiries, and ban the use of puberty blockers in minors, limiting any use of these experimental drugs to clinical trials.”—speech in favour of a successful motion, Queensland Liberal National Party (LNP) state conference, 5-7 July 2024. The LNP is the opinion poll favourite to oust the state’s Labor government at the October 26 election
Fantasy
Whistleblower psychiatrist Dr Jillian Spencer told GCN: “[The government and the Brisbane clinic] seem to have this idea that they’ll be able to turn gender medicine for children into a prestigious specialty.”
“The evaluation panel has tasked the gender clinic with developing a media campaign, in partnership with local [trans activist] groups, promoting gender-affirming care for children to the whole of Queensland, to the general public.
“They seem to have this vision that people are going to be enthusiastic to work in the [Brisbane] clinic and in the various clinics across Queensland, but I think that’s a total fantasy. Clinicians are going to be steering clear.”
Dr Spencer noted the Allan report was not built on a review of the scientific literature and failed to clearly acknowledge the weak evidence base—“so, it gives no reassurance to anyone working in these clinics that they’re doing the right thing.” And she believed that doctors approving affirmative medical interventions—i.e., within “a discredited model of care”—would remain exposed to medico-legal risk.
Some sceptics of the gender-affirming model got their hopes up when the Allan panel delayed its report supposedly to take account of England’s landmark Cass review, which found the evidence for puberty blockers to be so poor that this experimental intervention has been confined to a possible future clinical trial by the National Health Service.
In Ms Fentiman’s omnibus media statement, Dr Allan describes April’s Cass report as a “significant international publication” and says its findings were “actively considered” during his panel review.
“Essentially, [the Allan report has] cherry-picked the parts of the Cass review that suggest increasing the level of services, while completely ignoring the parts that criticise the model being used—particularly puberty blockers.
“The most concerning feature [of the Queensland government response] is the intention to develop a network of regional centres and [trans activist] NGOs, with the former acting as a funnel and the latter as ideological guardians or cheerleaders.”—Queensland academic psychiatrist Dr Andrew Amos, comment to GCN, 23 July 2024
Suicide scare
The Allan report devotes just six paragraphs to Dr Cass’s four-year review and manages to both misrepresent her work as a charter for expanding the besieged gender-affirming treatment approach, while seeking to cast doubt on her robust conclusions about the evidence base with an unexplained reference to “further debate about [their] accuracy.”
In the UK, the Cass review has been “debated” by trans rights activists—including prominent lawyer Jolyon Maugham and Guardian journalist Owen Jones—claiming on social media that young people denied puberty blockers will harm themselves and that there has already been a dramatic increase in suicides since 2020 when hormone suppression was restricted at the Tavistock gender clinic.
The new UK Labour government’s Secretary for Health, Wes Streeting, who is considering a permanent ban on puberty blockers to stop unregulated private provision, sought an expert fact-check from psychiatrist Professor Louis Appleby, who has worked in suicide prevention for 20 years and led the National Confidential Inquiry into Suicide and Safety in Mental Health.
Professor Appleby’s July 19 report found no support in the data for the familiar trans suicide narrative, which he said did “not meet basic standards for statistical evidence.”
And he directed a sharp rebuke at the retailers of this narrative, a rebuke that has international relevance.
He noted that the alarming claims by Mr Maugham had been “retweeted thousands of times by other campaigners and members of the public. They have been repeated by some leading journalists, though there is nothing to suggest that they have examined the evidence for themselves. They too have adopted the language of ‘dying children’.”
“The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide. One risk is that young people and their families will be terrified by predictions of suicide as inevitable without puberty blockers—some of the responses on social media show this.
“Another is identification, [whereby] already-distressed adolescents [are] hearing the message that ‘people like you, facing similar problems, are killing themselves’, leading to imitative suicide or self-harm, to which young people are particularly susceptible.
“Then there is the insensitivity of the ‘dead child’ rhetoric. Suicide should not be a slogan or a means to winning an argument.”
Professor Appleby noted that gender-distressed youth often also had depression, anxiety or autism, each a suicide risk factor in its own right, and he said the evidence for puberty blockers as suicide prevention was “unreliable.” He cited the recent study from Finland concluding that the suicide risk among the adolescent patients of gender clinics was linked to their psychiatric problems, not to the gender distress itself.
“It is unfortunate that puberty-blocking drugs have come to be seen as the touchstone issue, the difference between acceptance and non-acceptance. We need to move away from this perception among patients, staff and the public,” Professor Appleby said.
Dr Cass said in her final report: “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population [of gender-distressed youth], but the evidence found did not support this conclusion.”
Directly relevant findings from her review and its nine peer-reviewed research papers go unmentioned in the Allan report, including—
a poor rating for the three gender-affirming treatment guidelines7 used as benchmarks for reviewing the Brisbane clinic
concern about overlong hormone suppression as a result of the Brisbane clinic’s fast track towards puberty blockers
independently run systematic reviews—the gold standard when judging the quality of the scientific literature for a health intervention—showing the evidence for blockers and cross-sex hormones to be very weak and uncertain
Queensland paediatrician Dr Dylan Wilson said he believed the Allan report was “weak and contradictory”, lacked the necessary information, and provided “no clarity on whether children genuinely consent” to an intervention such as puberty blockers likely to lead to lifelong medicalisation, infertility, sexual dysfunction and serious risks to health.
He highlighted the inadequacy of the mini-audit of 93 patients seen for an initial session at the Brisbane clinic between February and April last year and tracked up until April 2024.
Their median age at the time of that initial session was 14. A pie chart from April 2024 shows 34 per cent discharged with no medical intervention deemed necessary by the clinic, 37 per cent still under assessment, 12 per cent on puberty blockers and 17 per cent on cross-sex hormones.
This may seem a modest level of medicalisation, but Dr Wilson points out that essential information is missing, including the range of ages, the reason for discharge and how many of those still under assessment were too young or too old for puberty blockers. From the scant data provided, it’s not possible to know what percentage of patients in early puberty—when they are considered eligible for puberty blockers—are in fact put on hormone suppression by the clinic.
In 2023, remember, there were 172 children started on blockers, 42 per cent of the number of new referrals (406) accepted by the clinic that year. And the number of patients on hormone suppression in the Allan review’s audit is just six per cent of the total commenced on puberty blockers over the full year.
Dr Wilson says a useful review would pull the charts for each of those 172 children, scrutinise their intake assessment, check the role of social stereotypes in the diagnosis of gender dysphoria, see if other explanations for distress were considered, and take note of “any red flags”.
“[A reviewer] should look at those charts and say, hang on, you puberty blocked this kid who’s got a horrendous history of abuse, you’ve puberty blocked this kid who’s got an eating disorder, you know, all these things,” he said.
“How often does a kid come and say, I’m trans, and [at the clinic] they say, no, you’re not—you’re just depressed, you’ve got disordered eating?”
The Allan report says it did not consider “subjective opinions on the ethical considerations of children and adolescents accessing gender services” and found the information in consent forms at the clinic to be “comprehensive”.
In Dr Wilson’s opinion, this dodges the reality—“I have spoken to patients who have been on hormone therapy for years who show little understanding of the impacts the treatment will have on their future relationships, despite regular attendance at [the Brisbane gender clinic].”
“So, when they talk about consent, I’ve got no doubt that they get people to sign a form and ask, do you consent? Even if you say to a child, do you understand this [treatment] will mean that you will have these problems, and they say, yes—that still doesn’t mean they consented.”
And despite the headline finding of the Allan report—that the Brisbane clinic “provides effective care from referral to discharge and that this care meets consumer needs and aligns with the guidelines”—there are troubling admissions.
These concerns and contradictions include—
the report asserting that care at the clinic is “contributing to improved health outcomes” and yet having to recommend that the clinic “formalise collection of clinical outcomes measures inclusive of pre- and post-intervention measures” and “develop a system to monitor long-term outcomes”
the clinic being urged to “identify an existing clinician within the [clinic] who has extended knowledge of the risks and long-term fertility implications of medical treatment, and ensure this consultation is offered and accessible to all consumers and their families as part of the standard clinical assessment and intervention pathway,” yet at no point openly acknowledging that children are being sterilised
the clinic deciding in late 2022 that patient demand was so high it could no longer prioritise mental health support and redirecting patients to over-stretched external practitioners, yet the report pointing out the “high clinical complexity” of mental health problems among the clinic’s patients
practitioners who refer patients to the clinic being concerned that the clinic did not have the right priority system, “with referrals for patients experiencing escalating mental health issues related to their gender dysphoria not being prioritised, posing clinical risks”
the three treatment guidelines being used by the clinic failing to “outline specific clinical processes or pathways for the children and adolescents seeking support to guide clinical services”
clinicians elsewhere in Queensland’s Child and Youth Mental Youth Service (CYMHS)—of which the Brisbane gender clinic is part—saying that the model of care used by the clinic was “not well shared within CYMHS, leading clinicians to question the referral criteria, assessment process, treatment options, and long-term outcomes”
the “ethical debate about children and adolescents accessing services for the treatment of gender dysphoria” being framed by the Allan report as an “external source of pressure”, rather than demanding a serious response
Last December, GCN broke the news that the Queensland Children’s Gender Service was to be reviewed, and noted that the plan to benchmark this gender-affirming clinic against the activist-affirmative “Australian standards of care” did not inspire confidence in open inquiry. Announcement of the review followed public statements of concern by Dr Spencer and Dr Wilson. Neither was contacted about their concerns during the review. GCN put questions to Queensland government health authorities responsible for the Brisbane gender clinic, but they refused to comment because they claimed GCN was not a “recognised news media outlet.” GCN does not dispute that gender-affirming clinicians believe their interventions help vulnerable youth.
Hormone suppression drugs are used off-label to block the natural sex hormones that drive adolescent development towards adulthood.
There is no available data to show the extent of this private prescribing.
Data for January-March 2018 was not available.
Only Dr Allan’s name was made public by the government. Three of the other six members of the panel have links to the gender-affirming lobby group, the Australian Professional Association for Trans Health (AusPATH), among them AusPATH president Professor Ashleigh Lin and trans activist Jeremy Wiggins.
In an international survey commissioned by the Cass review, it was reported that one Australian clinic—it appears to be the Brisbane gender service—said it did not screen new patients for autism because it held the view that these screening tools were “not accurate in [the] trans population.”
An internal work instruction document for the Brisbane gender clinic says that mastectomy is an “integral part of the transition process for many trans males and non-binary young people [i.e., for females]”. The clinic itself does not perform this surgery. The instruction document for clinicians says that “in exceptional circumstances” this “chest reconstructive surgery” may serve the best interests of a minor, implying that the clinic would refer girls to a private surgeon. The document notes that the Family Court had found two 15-year-old girls competent to consent to trans mastectomy.
The “Australian standards of care” guideline issued by the Royal Children’s Hospital Melbourne is “untrustworthy”, according to a pioneer of evidence-based medicine, Canada’s Professor Gordon Guyatt. The other two guidelines used by the Brisbane clinic are from the Endocrine Society and the World Professional Association for Transgender Health (WPATH). The Endocrine Society document was found wanting by an investigation in the British Medical Journal. WPATH is embroiled in a scientific misconduct scandal.
Thank you so much Bernard, really appreciate your work. Shared.
Bernard, your research and reliable writing in this area is very much appreciated by those of us in Queensland actively speaking out against the gender affirming treatment practices and writing submissions, letters to ministers and other politicians. Your work is so valuable for our advocacy of child safeguarding and the rights of women and girls. Thank you.