Under-18 transgender surgery caution urged after false claims scandal

Australia’s psychiatrists have been urged to be cautious about giving official backing to gender clinic treatments for under-18s.

An increasing number of teenagers around the developed world seek medical treatment for distress about their biological sex.

Australia’s psychiatrists have been urged to be very cautious about giving official backing to gender clinic treatments for under-18s after an international scandal over false claims of mental health benefits for transgender surgery.

The Royal Australian and New Zealand College of Psychiatrists should be “extremely careful” before endorsing so-called “gender affirming” hormonal treatment and surgery for minors, according to Philip Morris, president of the National Association of Practising Psychiatrists whose members look after patients in the private and public sector.

The country’s biggest gender clinic at the Royal Children’s Hospital in Melbourne has asked for more public money to start double mastectomies on girls under 17 who identify as male, with director Michelle Telfer claiming in July 2019 that “chest reconstructive surgery” improves mental health.

This month, the prestigious Journal of American Psychiatry had to publish an extraordinary correction to an October 2019 US-Swedish paper hailed as a global breakthrough in a field where even gender affirming clinicians admit the evidence is short-term and low-quality.

The peer-reviewed paper was the first to use official Swedish data, which is unusually comprehensive, to claim that surgery such as mastectomy or genital reconstruction reduced the need for mental health treatment by 8 per cent a year over the ensuing decade.

“No longer can we say that we lack high-quality evidence of the benefits of providing gender-affirming surgeries to transgender individuals who seek them,” said study co-author John Pachankis, who directs the LGBTQ Mental Health Initiative at Yale University.

Newsweek magazine highlighted the research finding and quoted unnamed “scientists who say such (surgical) interventions must be as easy as possible to access”.

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On August 1, the American journal published a correction, an editorial and letters from a dozen psychiatrists, clinicians and researchers in four countries identifying multiple flaws in the 2019 paper, with the conclusion that the data showed no improvement in mental health after surgery or hormonal treatment.

The correction said the authors agreed “with many of the points raised” after the letters triggered statistical reviews. They reanalysed the data, and found “no advantage” for mental health after surgery.

The authors’ original study had detected no benefit after hormone drugs but media coverage focused on the surgery success story.

“(The correction) has great international significance,” said Paul McHugh, one of America’s most distinguished practitioners, former chief psychiatrist at Johns Hopkins Hospital in Baltimore and co-author of one of the letters run by the journal.

He said the correction would make gender affirming advocates “a lot more cautious” when making scientific claims because “they’ll know people are watching”.

“Peer review is not going to God, it’s going to the common thought of the day, which in psychiatry is usually good, but every 10-15 years it gets lost in some misadventure,” Professor McHugh told The Australian.

He predicted the excesses of gender affirming treatment — like the 1990s “enthusiasm” over repressed memory and multiple personality — would be reined in by the courts, not by the psychiatric profession.

Swedish neuropsychiatrist Christopher Gillberg, one of the world’s top autism researchers, put his name to one of the letters critical of the 2019 paper, pointing out its positive claims ignored any post-surgery suicides.

Four of the letter-writers serve as clinical and academic advisers to the new watchdog group the Society for Evidence Based Gender Medicine.

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The 2019 US-Swedish paper has been hailed by one of Australia’s biggest youth news sites, pedestrian.tv, in an article promoting a change.org petition by a teenage activist, Tennille Fleming, lobbying federal Health Minister Greg Hunt for trans surgery to be fully covered by Medicare. The petition has more than 25,000 signatures.

Media outlets which reported the 2019 study’s result have yet to cover the journal’s correction.

RCH researcher Ken Pang in 2018 documented spikes in new referrals at the gender clinic in the month following three media items by the ABC and The Age newspaper between 2014 and 2016. This coverage showcased the clinic and told positive stories of young people on puberty blocker drugs and cross-sex hormones.

Treatment guidelines from Dr Telfer’s RCH clinic, promoted as “Australian standards”, make a case for trans mastectomies for girls as young as 16 with “gender dysphoria” (distress at feeling “born in the wrong body”).

In September, the RANZCP quietly dropped its endorsement of these guidelines from its LGBTIQ+ mental health policy statement, following concerns reported by The Australian.

The college set up a group to review the evidence for the RCH guidelines and gender dysphoria treatment.

Asked if its unnamed experts would take into account the US journal’s correction, a spokeswoman for the college said they would look at the relevant “literature and evidence-based practice”.

“The completion date (for the RANZCP review) is yet to be confirmed depending on the review process which is independent and rigorous,” a spokeswoman for the college said.

A previously unreported submission shows the RANZCP, the Royal Australasian College of Physicians and a state-funded trans activist group the Gender Centre collaborated in 2016 to ask the NSW government for $8m over four years to set up an RCH-style gender affirming network of clinics with The Children’s Hospital at Westmead in Sydney as the centre. The proposal cited “close consultation” with Dr Telfer.

NSW Health Minister Brad Hazzard at a construction zone of Westmead Hospital

In 2018-19, the government provided $160,000 towards the project.

Under-18 trans medical treatment in NSW is rising but remains on a small scale compared with Victoria, Queensland and Western Australia.

On Tuesday, responding to questions about the 2016 proposal, NSW Health Minister Brad Hazzard revealed for the first time that late last year he had asked his department for a review of treatment for youth gender dysphoria.

This review began in November 2019 and was separate from the audit and review of this treatment agreed by the Australian Health Ministers’ Advisory Council with a reporting date of July 17, a spokeswoman for NSW Health said.

The NSW-specific review was expected to finish in “the coming months” and would rely on “available evidence and consultation with clinicians, service providers and consumers”.

“The review will be used to inform improvements to the provision of health services for trans, gender diverse and non-binary children and young people in NSW.”

The Australian sought comment from Dr Pachankis, his Swedish co-author Richard Branstrom, and RCH.