Swedish clinic moves first to halt trans drugs for children

Australian health ministers are being urged to act as Sweden’s top clinic moves first to end routine treatment with hormone drugs.

There has been a puzzling global surge in teenagers feeling a disconnect between their bodies and an inner sense of “gender identity”.

UPDATED | Australia’s health ministers are being urged to act as Sweden’s leading gender clinic becomes the world’s first to end routine treatment of minors with hormonal drugs lacking good evidence of safety.

Stockholm’s Astrid Lindgren children’s hospital, which is part of the Karolinska medical powerhouse famous for awarding the Nobel prizes, has cited risks including cancer and infertility when ordering that puberty blocker drugs and cross-sex hormones may only be given to under-18 patients as part of clinical trials under strict ethics control.

In Australia, puberty blockers have been prescribed for children as young as 10, and nationally followed treatment guidelines from the Royal Children’s Hospital in Melbourne recommend doing away with a minimum age of 16 for cross-sex hormones, and suggest transgender surgery such as mastectomy as young as 16.

The stated rationale for these early medical interventions — known as the Dutch protocol after an innovative Amsterdam clinic — is to ease the distress of gender dysphoria and enable a more successful medical transition to a body resembling that of the opposite sex.

The decision by Sweden’s Karolinska hospital cites the English High Court’s Tavistock clinic finding that so little is known about puberty blockers that they must be regarded as experimental, and follows a series of independent international reviews concluding that the evidence base for affirmative treatment is weak with no data on long-term safety.

Video: The Trans Train 2 from Sweden’s national broadcaster SVT

Tasmanian Liberal Senator Claire Chandler, who has been campaigning for open debate and the release of patient data from Australian children’s hospital gender clinics, said the Swedish reversal made sense given growing global concern.

“What is surprising and shocking is that state governments and health departments in Australia are yet to act on these concerns, and instead continue to try and evade scrutiny on their practices in their gender clinics,” she told The Australian.

This newspaper sought comment on the Swedish development from the health ministers of Victoria, Queensland and Western Australia, home to the country’s three large gender clinics, as well as from NSW, where there are signs of alarm among clinicians at the risks of the medicalised affirmative treatment model. No minister would comment.

“It is a national scandal that state governments are giving experimental treatments with unknown long-term outcomes to an undisclosed number of children, while ignoring expert concerns and threatening parents with jail (under new criminal laws against ‘conversion therapy’) if they discuss those concerns with their children,” Senator Chandler said.

The international Society for Evidence-Based Gender Medicine, which has highlighted the poor quality data used to justify these hormonal and surgical interventions with minors, said the Karolinska’s stand was “a watershed moment”.

“One of the world’s most renowned hospitals (has called) the ‘Dutch Protocol’ experimental and discontinuing its routine use outside of research settings,” SEGM said in a statement.

It said the Karolinska’s new rules for assessment of the maturity of young patients and disclosure of treatment risks and uncertainties mean it was unclear if children under 16 would be eligible for these hormonal drugs even in clinical trials.

In a March policy change document, the Swedish hospital noted that the English judges’ Tavistock ruling “specifically states that informed consent for (puberty blockers) is highly doubtful, if at all possible, under 16 years of age”.

Video: Senator Claire Chandler calls for release of gender clinic data

SEGM director Roberto D’Angelo, an Australian psychiatrist, said the Swedish shift to caution followed Finland’s new psychotherapy-first treatment guidelines and systematic reviews and research papers in the UK and Australia confirming the lack of quality evidence for risky medical interventions by “gender affirming” clinics.

“These respected sources should prompt some kind of urgent inquiry into the treatment of gender dysphoria in Australia, given we are hearing these concerns from independent sources all around the world, which are certainly not anti-trans,” Dr D’Angelo told The Australian.

Meanwhile, Australia’s National Association of Practising Psychiatrists under president Philip Morris has fleshed out its cautious approach to treatment of under-18 gender dysphoria with a new statement advising non-medical interventions such as psychotherapy as “first-line treatments” before any thought of experimental puberty blockers.

The document, published on Sunday, stresses the rapid changes of adolescence, the likelihood that in most cases a sense of alienation from the body will resolve with maturity, and the need for clinicians to look at the total picture explaining a young patient’s distress, rather than focusing on gender in isolation.

“Increasing numbers of individuals who have undergone hormonal treatment and surgical interventions subsequently report experiencing regret and a wish to detransition (to cease hormones and re-embrace their birth sex),” the NAPP guide says.

“They describe significant psychological and physical suffering, including loss of fertility and sexual function as a consequence of decisions made when younger.”

Sweden's prestigious Karolinska Hospital in Sweden affirms the precautionary principle regarding treatment of gender dysphoric minors. Full document: https://t.co/N4a0Br5KkSpic.twitter.com/hTPeSnMLOL

— Dr Jordan B Peterson (@jordanbpeterson) May 5, 2021

Treatment guidelines promoting gender medicine are coming under increasing scrutiny, with a systematic review last month in the BMJ Open journal highly critical of the main international guideline from the World Professional Association for Transgender Health.

Five of the six reviewers said they would not advise clinicians to use the dated 2012 WPATH guideline, which was rated low in rigour of development, applicability and editorial independence.

This WPATH document is relied upon by the 2018 RCH treatment guidelines, which admit the “scarcity of high quality” evidence but have been promoted as the “world’s most progressive” and are used by all the major children’s hospital gender clinics in Australia.

However, there are signs of NSW taking a more independent approach, with its own treatment guidelines and a new “service model” coming.

Gender clinicians at The Sydney Children’s Hospital in Westmead — home to the state’s main gender service — recently published an internationally significant paper raising multiple concerns about the medicalised affirmative model.

That April paper by Westmead psychiatrist Kasia Kozlowska and colleagues refers to “yet to be announced” guidelines from the health ministry.

NSW Health did not answer The Australian’s questions about this apparent policy change, but said gender dysphoria care was guided by “laws and policies”, and “also informed by” current guidelines, including the RCH document.

In April last year, NSW Health appeared to give more weight to existing guidelines, confirming it “still uses” the WPATH, Endocrine Society and RCH documents, which all promote Dutch protocol medical interventions.

In a letter this month to NSW MP Greg Donnelly, NSW Health Minister Brad Hazzard says the English Tavistock ruling is “not binding in Australia”, but he offers an assurance that his department will “vigilantly monitor” local law on patient consent, which he says is “likely” to continue to develop with “advances in medical evidence” on gender dysphoria.

Sweden’s internationally renowned neuropsychiatric researcher Christopher Gillberg told The Australian in 2019 that he believed youth gender clinic treatments were “possibly one of the greatest scandal­s in medical history”.

A 2018 Swedish proposal to lower the age for trans genital surgery, without parental consent, from 18 to 15 sparked an outcry and the country’s public broadcaster SVT screened a widely watched, three-part investigation of gender clinics called the Trans Train, which was followed by official scrutiny of the treatment evidence.

The Australian sought comment from the Swedish hospital, RCH, and the gender clinicians’ lobby AusPATH.