Contentious UK gender medicine report prompts reflection, outrage in Australia
By Michael Bachelard and Aisha Dow
A new policy in the United Kingdom to restrict the medical treatments available to trans and gender-diverse young people has raised fresh questions about Australia’s approach in one of the most sensitive areas of medicine and prompted a fierce defence from LGBTQ advocates.
British paediatrician Hilary Cass, who has spent four years on behalf of the National Health Service examining what is known as “affirming care” for transgender young people, published her final report on Tuesday night Australian time.
The NHS announced last month it would stop routinely prescribing puberty blockers to children with gender dysphoria.Credit: iStock
The report represents a serious challenge to the accepted approach to gender medicine in Australia, where affirming care is practised nationwide and where the number of young people seeking it – particularly those born as girls – has exploded in the past decade.
Affirming care starts from the premise that a child’s statements about their gender identity should be taken seriously and acted upon. When medical treatment of a young person is recommended, they might begin drugs to stop their puberty from the age of 11 or 12.
If they persist in their desire to change gender, they can move to the next stage: cross-sex hormones – oestrogen or testosterone – so their physical form more closely resembles their gender expression.
It’s this regime that Cass’ report calls into question. Over more than 300 pages, she cautions that there is “not a reliable evidence base upon which to make clinical decisions” in transgender medicine because the scientific evidence is of such poor quality.
The NHS announced last month that it would stop routinely prescribing puberty blockers to children with gender dysphoria and restrict their use to a clinical trial as a result of the Cass review.
The rationale for using drugs to suppress puberty in children who say they are transgender “remains unclear” and the effects of the drugs are unknown, her report states.
It’s often argued that puberty blockers are urgent and necessary to prevent mental health harm, up to and including suicide. But Cass also found the evidence was weak regarding their impact on mental health conditions and gender dysphoria – a feeling of distress that your gender identity does not match your physical form.
The second phase of treatment – the use of masculinising or feminising hormones – in those under the age of 18 “also presents many unknowns”, according to Cass. Hormone treatments can have irreversible effects, such as a permanently deeper voice and facial hair for people born as women. They can also lead to infertility.
Cass said hormones from age 16 should be an option but recommended “extreme caution” and a “clear clinical rationale” as to why the person could not wait until they were 18. Clinicians, Cass wrote, were unable to determine with any certainty which children and young people would go on to have an enduring trans identity.
“For most young people, a medical pathway will not be the best way to manage their gender-related distress,” Cass wrote.
In response to the report, Australian governments and health services backed their existing approach.
The report also prompted an immediate backlash from LGBTQ groups, who said it ignored the consensus of major medical bodies around the world and lacked relevance to Australia.
Vice-president of the Australian Professional Association for Trans Health (AusPATH)Dr Portia Predny, disputed Cass’ conclusion that the evidence base for affirming care was weak, saying that, for ethical reasons, it was not feasible or ethical to conduct randomised control trials to collect the highest quality of evidence.
Carlie Morris of Parents for Transgender Youth Equity said “young people know who they are and can work with clinicians to seek out options for their care”.
The Royal Children’s Hospital in Melbourne, which runs Australia’s largest children’s gender service, did not respond when asked if it would reassess the evidence for gender-affirming treatment of children in the wake of the policy change in the UK.
“As always, our gender service is underpinned by both national and international research methodology, and we will continue to monitor outcomes that will inform best practice,” a spokesperson said.
The NSW Health Department referred to a review already being conducted by its clinical advisory group into emerging evidence, and Health Minister Ryan Park said his department continued “to monitor developments in the evidence”.
The release of the report coincides with the finalisation of a Queensland Health evaluation of its children’s gender service.
A spokesperson for Australian Health Minister Mark Butler backed comments from LGBTQ groups and several experts that the system for the treatment of transgender children was different in Australia compared with the UK, but nonetheless dubbed the Cass report “significant”.
“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,” they said.
The Australian Medical Association has historically fully supported gender-affirming care, saying there needs to be easier access to it. However, AMA president Professor Steve Robson backed a number of elements of the Cass report, including a call for more research.
Others supported the recommendations.
A parent from PAGD, a Victorian support group for families questioning affirming care, who wanted to remain anonymous for fear of public backlash if they were identified, said: “We hope this is a wake-up call to Australian medical and educational institutions and that we will finally see some caution and questioning around what is happening to our children.”
The parent said that “in far too many cases our concerns have been ridiculed, our input ignored and our knowledge of our own children dismissed” by schools, professionals and politicians.
Mel Jefferies, a young woman who regrets her gender transition and has returned to her birth gender, also welcomed the Cass report.
Mel Jefferies describes herself as a “detransitioner”.Credit: Chris Hopkins
“I made permanent decisions off temporary feelings by medically transitioning. And the whole medical system is enabling that … if people are pushing this and causing substantial harm; how do you come back from this?”
Equality Australia legal director Ghassan Kassisieh said Australia required parental consent before young people could access treatment, so it was “already too difficult for trans young people to access the care and support they need”.
Associate Professor Ada Cheung.
Endocrinologist and head of the University of Melbourne’s trans health research group Associate Professor Ada Cheung said there was already substantial observational evidence reporting on the wellbeing of transgender young people on puberty blockers.
She noted that four studies rated as high quality showed those treated with puberty blockers had less depression and anxiety, less self-harm and suicidality and fewer problems with peer relations.
“The Cass report goes against the consensus of professional medical associations around the world and I don’t think it 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.”
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