There’s been a lot of discussion this week about the adequacy of medical care provided to children with gender dysphoria and whether change is needed.
It’s been sparked by a landmark investigation into gender-affirming care offered via the National Health Service [NHS] in England, conducted by well-known paediatrician Hilary Cass.
The outcomes of the report are designed to reshape how publicly-funded care is provided to young people in England.
Her report, known as the Cass Review, spans hundreds of pages and calls for sweeping changes to how the NHS provides treatment to young people through its gender clinics.
In a nutshell, it recommends the service significantly limit the prescribing of medications — colloquially known as puberty blockers — for people aged under 18 and for patient care to be multi-disciplinary and centred around mental health support rather than medical interventions.
It’s a recommendation the NHS England adopted last month, in anticipation of the findings.
“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,” the NHS England wrote in March.
“NHS England recommends that access to [puberty blockers] for children and young people with gender incongruence/dysphoria should only be available as part of research.”
Prior to the change, the drugs had been prescribed to patients with gender dysphoria in England. Though, according to UK media, it was estimated fewer than 100 people were on the drugs via the NHS. Those patients would be allowed to continue to take them.
In her report, Dr Cass said she made the recommendations because of a lack of scientific evidence into the long-term use of the medications.
“You must have the same standards of care as everyone else in the NHS, and that means basing treatments on good evidence,” Dr Cass wrote, directly addressing gender dysphoric children.
“I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you.”
Dr Cass’ findings were based on a series of systematic reviews of the medical evidence and international treatment guidelines undertaken by University of York.
“This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint,” she wrote.
As part of the work, researchers identified 23 guidelines published between 1998 and 2022 that contained recommendations about children and young people with gender dysphoria, four of those were international, three were regional and 16 were national.
Dr Cass went on to call for both the scientific community and patients who are taking puberty blockers to come together to study their use.
As a result, questions are being asked about whether those findings should have implications in other countries, like Australia, where gender affirming care is available.
Will things change in Australia?
It’s not out of the question, but there is deep resistance.
In Australia the review has been acknowledged but most doctors and institutions, and even the government, have cautioned against applying the findings here, arguing the settings are very different.
Here, puberty blockers are only subsidised for patients who have certain cancers or those experiencing early puberty. Though, patients can access them without subsidy.
Health Minister, Mark Butler, described the Cass Review as “significant” but said the clinical pathways in Australia were different to those offered in the UK.
“Clinical treatment of transgender children and adolescents is a complex and evolving area in which longer term evidence to inform treatment protocols is still developing,” he said.
“Everyone, including the states and territories who are responsible for these services in Australia, will take the time to consider this review which has just been released.”
In 2020, the Australian government rejected calls for a national inquiry into gender affirming care for young people, saying it was concerned it would negatively impact their wellbeing.
That followed the advice provided by the Royal Australian College of GPs, which warned such an inquiry would not increase scientific evidence but would further harm vulnerable patients.
Who is sceptical of the review’s findings?
A recurring bone of contention is around the quality of existing research. Some advocates and doctors argue the data available is strong enough despite the Cass Review suggesting otherwise.
Head of the Trans Health Research group at The University of Melbourne, Associate Professor Ada Cheung, said she did not see any merit in carrying out a similar review here.
“The Cass report goes against the consensus of professional medical associations around the world, and I don’t think is relevant to practice in Australia,” she said.,
“It downplays the risk of denying treatment to young people with gender dysphoria and limits their options by placing restrictions on their access to care.”
Associate Professor Cheung said, unlike the UK, Australia already had a coordinated multidisciplinary approach to care, where puberty blockers were provided as part of specialist hospital-based teams, as recommended by Australian guidelines.
“The way that gender affirming care is accessed and provided in Australia is substantially different to the NHS.”
The Royal Children’s Hospital Melbourne, which penned the guidelines, declined to comment for this story.
The head of Transcend Australia, the national body for trans, gender diverse, and non-binary young people, suggested the review excluded good research.
“Families deserve to be provided with all the available evidence about medical treatment, which the Cass Review has failed to do by excluding a significant amount of global research,” Transcend Australia CEO Jeremy Wiggins said.
Dr Portia Predny, from the Australian Professional Association for Trans Health agreed, adding that applying the findings here would be “flawed” because the review specifically looked at the NHS in England.
“In Australia, our guidelines for gender affirming care for young people already prioritise holistic, individualised and person-centred care with the involvement of multidisciplinary teams of clinicians with all kinds of areas of expertise, to help and support young people to navigate their gender journey,” Dr Predny said.
Who is supportive of the findings?
In the UK, the review has been widely welcomed by senior academics and the medical profession. Though, some doctors and advocates are worried that patients will be blocked from receiving the care they need.
The findings were cautiously welcomed by Ashley Grossman, an Emeritus Professor of Endocrinology with the University of Oxford.
“It may be that a small number of these children should in the long-term transition to a different sex, but routine puberty blocking treatment for this use has not yet been adequately studied, and many of these children may have other problems for which they need help,” Prof Grossman said.
“More carefully run clinical trials are needed so that we can understand how and when such agents are justified and of benefit.”
There is also some divide in Australia.
Dr Jillian Spencer is a child and adolescent psychiatrist who has long advocated against gender affirming medical interventions and has welcomed the review’s findings.
“I think it signals a return to careful and evidence-based treatment approaches rather than treatment approaches driven by activists,” she said.
She also raised concerns that Australia’s clinical guidelines were more heavily skewed towards social outcomes as opposed to medical ones and remained critical of the services provided by specialist gender clinics here.
“There has been failure to acknowledge the risks and harms of transitioning children,” she said.
Dr Spencer was stood down from clinical duties at the Queensland Children’s Hospital last year and is awaiting the outcome of an investigation over a complaint from a young transgender patient.
She’s contesting the action with a case to be heard by the Queensland Industrial Relations Commission.
Speaking to the ABC, Dr Spencer cited FOI documentation showing there were 172 prescriptions initiated for puberty blockers last year at Queensland’s Gender Service and said she was worried by that rate.
“The lesson for Australia is that we must find a way to freely discuss health care issues regardless of their sensitivity. In this case, children have been harmed by the mainstream media and the government being unwilling to examine concerns that were repeatedly raised by health professionals and parents over many years.”
The Australian Medical Association declined to comment, but provided a statement from earlier this year which said, “people who are LGBTQIASB+ thrive in health care environments where they feel safe, affirmed, respected and understood”.
It also called for greater access to gender-affirming treatment.,
The ABC has also approached the RACGP for comment.
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