Doctors step up calls for gender care re-examination

The battle over gender affirmative medicine in Australia has intensified with a call to arms by two experienced psychiatrists for their fellow doctors to resist the pressure of activism driving treatment.

Professor George Halasz. Picture: Alex Coppel

The battle over gender-affirmative medicine in Australia has intensified with a call to arms by two experienced psychiatrists for their fellow doctors to resist the pressure of activism that has triggered the widespread “subordination of clinical governance to social and political goals” in the rush to affirm distressed children’s chosen gender.

The psychiatrists used an academic paper in a top psychiatry journal to urge the medical profession to heed the “cautionary tale” posed by the healthcare scandal that unfolded at London’s Tavistock clinic and in British compensation cases they say are directly relevant to Australia.

Monash Medical Centre child and adolescent psychiatrist George Halasz and Andrew Amos, an academic psychiatrist who has previously held a training role with Queensland’s health department, went as far as to remind doctors of their obligation to observe the Hippocratic oath in questioning the evidence base of affirmative medicine.

In an article in the journal Australasian Psychiatry, They urged doctors to examine the ethics of a model in which powerful hormone drugs are prescribed despite a lack of evidence that the affirmation of a child’s perceived gender identity and subsequent medical transition eases teenagers’ mental distress.

“The natural history of gender dysphoria suggests two critical ethical questions: first, is the ‘transition pathway’ – social, medical or surgical – in the best interest of the child?” the two psychiatrists wrote. “Second, is that pathway consistent with the principle ‘first, do no harm’?”

But even as the explosive article was published, paediatricians and their colleagues at the Royal Children’s Hospital in Melbourne – home of the nation’s leading experts in gender-affirmative medicine and the self-appointed setters of quasi-national guidelines adopted by most of the country’s children’s hospitals – quietly published an updated version of their standards of care that endorse a radical expansion of the affirmative model.

The new guidelines endorse the prescription of puberty blockers and cross-sex hormones by general practitioners, outside a multidisciplinary model led by specialist children’s hospitals – the model explicitly endorsed as of utmost importance by the Cass Review in the UK.

The review by pediatrician Hilary Cass of the Tavistock clinic’s Gender Identity Development Service began in 2022 and triggered the institution’s closure. It confirmed a limited evidence base for gender-affirming care, systemic failures of clinical governance, and unjustifiable risks of harms to children and families, amid re-examination of the affirmative model in academic literature and policy in countries throughout Europe.

Dr Andrew Amos. Picture: Peter Eve

Despite this, the new RCH guidelines do not reference the Tavistock fallout at all, or the fact puberty blocker drugs are only able to be prescribed in the context of a clinical trial now in England. Nor do they mention the growing caution that has prompted a rollback of the medical model in countries that had previously adopted it, including Finland, amid the recent scientific discrediting of the Dutch “affirmation model” on which Australia’s approach is still based.

“It is unrealistic that all trans and gender-diverse adolescents in Australia will be able to directly access comprehensive specialist paediatric services, especially with these specialist disciplines co-located within a public health service,” the new guidelines state. “Provision of a multidisciplinary team approach with co-ordination of care from general practitioners, private specialist practitioners and community-based clinicians can be an effective alternative in ensuring best practice and accessibility to medical intervention.”

The RCH was approached for comment and declined.

Clinicians pushing for clinical accountability and transparency said they were stunned that the new guidelines fail to consider any of the newly emerging evidence or systematic reviews post-2020 that have dismantled the credibility of the original Dutch model that underpins gender-affirmative medicine and also cast doubt on the efficacy of the approach, highlighted in Australia this year by research clinicians at the The Children’s Hospital at Westmead.

In interviews with The Weekend Australian expanding upon their academic paper, Professor Halasz and Dr Amos expanded upon their concerns that there were “major risks associated with gender-affirming care”. Yet the new version of Australia’s guidelines “reads as if there is simply no controversy”.

Professor Halasz said it was beyond time for Australia’s children’s hospitals – in particular in Melbourne, Brisbane and Perth – to review their approach.

“I think it’s wise that any hospital that has been following what’s happened to the Tavistock to start to distance itself as much as possible, as urgently as possible, lest they suffer the same fate,” Professor Halasz said. “What I would ask is, where is the transparency? Where (are) the outcomes of the procedures, whether they are social transitioning procedures, or medical procedures of prescribing puberty blockers or cross-sex hormones?

“And where is the data on the number of surgical interventions that follow after the Royal Children’s Hospital care is finished and these patients transition over to adult services? Where is the data? Or the follow-up to document detransitioners? Where is the evidence?”

The psychiatrists said the rise of gender-affirmative medicine had been heavily influenced by trans activist groups whose lobbying was aggressive and intimidatory. And that culture had flowed through into medical training. “As someone involved in the education of training psychiatrists, I am particularly concerned at how effective trans advocacy has been in training young doctors to reflexively reject any evidence that there might be negative consequences to gender-affirming care,” Dr Amos said. “Trainees appear to believe that simply acknowledging there are alternative approaches to gender dysphoria actually threatens harm to the transgender community. I would describe that as magical thinking.

“I think there’s been a failure of leadership across medicine. Individual practitioners have been able to have huge influence because medical colleges have not stepped in to provide guidance.”

Professor Halasz, who trained in the UK and was in close contact with doctors who watched the Tavistock scandal unfold, described the rise of gender-affirming medicine as taking place within a radical form of social activism. “It was a culture of intimidation, silence, and I think threat,” the professor said. “And I just thought ‘this is so outside of my understanding of what medicine is about’.”

The psychiatrists said they were concerned by the suspension of Queensland specialist child psychiatrist Jillian Spencer, who had come into conflict with hospital bosses at the Royal Children’s Hospital in Brisbane over clinical practice in treating gender-questioning children.

Dr Spencer, a vocal critic of affirmative care, has been stood down from her role as a senior staff specialist at the hospital for months following a patient complaint – a fact that concerns Dr Amos.

He said it has been very difficult to get psychiatrists to make public statements about gender dysphoria even though the majority appeared to share a more moderate, exploratory approach. Doctors were afraid for their professional reputations.

“The major reason for this fear is that trans advocates appear to be both aggressive in their rhetoric, and unwilling to engage in any discussion that does not adopt their basic viewpoint,” Dr Amos said. “While I do not know the specific details, the protracted suspension of child psychiatrist Jillian Spencer for expressing an alternative view of the approach to gender dysphoria appears to have confirmed the real threat behind such fears.”

And the overriding of parents’ frequent gut instinct for caution over affirmation had damaged psychiatry as a profession, according to Professor Halasz.

“Our profession is entrusted by parents to do what’s in the best interest of their child,” he said. “The trust that we have built up with families over years, I believe, actually has been absolutely shredded by this process.”