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Denying trans teens treatment ‘cruel and unethical’: GP


Michelle Wisbey


16/04/2024 4:35:28 PM

The UK’s Cass Review calls for puberty blockers to be limited in favour of mental health support, but local GPs say access to care is key in Australia.

Person wrapped in transgender flag.
Around 1.2% of Australian school children are thought to identify as transgender.

A new report into gender-affirming care in the United Kingdom has created sweeping and divisive changes to its healthcare system, but Australian GPs are concerned about applying its recommendations locally.
 
The Cass Review, named after its Chair, high-profile paediatrician Dr Hilary Cass, was commissioned by the NHS to recommend how best to improve gender identity services and ensure children are offered the safest and most effective care.
 
Handing down her findings last week, Dr Cass made 32 recommendations for change, the most prominent of which was to severely limit young peoples’ access to puberty blockers due to a lack of information and scientific evidence about their impacts.
 
‘The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health,’ the report said.
 
‘The use of masculinising/feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population.
 
‘The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.’
 
A ban of the medications was formally adopted by the NHS before the review’s official release, after it agreed there is ‘not enough evidence to support the safety or clinical effectiveness’ of the drugs.
 
But health experts in Australia have warned against comparing our healthcare system to the NHS, saying the review’s findings cannot be directly compared.
 
RACGP Specific Interests Transgender and Gender-Diverse Healthcare Chair, Dr Michelle Dutton, told newsGP Australia has been actively working towards improving accessibility of care for transgender people at all levels of the healthcare system.
 
She said while this is becoming increasingly available, there is more to be done, and the Cass Report does not consider the harms which occur when young people are denied access to treatment.
 
‘School refusal, impact on relationships with self and others, suicidal ideation, and self-harm are very real consequences of young people not being supported in the way that they need to be, and this does not seem to be acknowledged as much as it should be,’ Dr Dutton said.
 
‘Gender-affirming care in Australia, especially for young people, has always emphasised a holistic, patient and family-centred approach which recognises the complexity that exists around helping young people make important decisions about their bodies and their health.
 
‘Research and evaluation of outcomes is already embedded in many of our tertiary gender services in Australia.’
 
The Cass Review recommended that gender-affirming services operate to the same standards as other services seeing children and young people with complex presentations and additional risk factors.
 
It also called for services to establish a separate pathway for pre-pubertal children and their families, and extending services for regional children.
 
But in Australia, Dr Dutton said more data is needed to allow GPs to offer best-practice patient care.
 
‘We all want what is best for our patients and our patients deserve that,’ she said.
 
‘Data is currently limited because trans healthcare research was not given the funding it deserved until relatively recently, but to then use this as a reason to deny trans people access to certain treatments is cruel and unethical.
 
‘We can help guide people in decision making where uncertainty exists without denying treatment altogether, and we can do this while continuing to gather data to inform future shared decision making – it cannot and should not be one or the other.’
 
It is currently estimated around 1.2% of Australian school children, about 45,000 young people, are thought to identify as transgender; however, the true prevalence remains unknown.
 
Dr James Best, Chair of RACGP Specific Interests Child and Young Person’s Health, told newsGP giving young people access to multidisciplinary teams and specialist services is key, but currently lacking in Australia.
 
‘The children’s hospitals, we need clinics in this area, and we need more and better access to them because there is very limited access at the moment,’ he said.
 
‘It’s also really important that access is given from a GP point of view too, because we want to be able to refer our patients to that sort of service.
 
‘It’s all about the multidisciplinary team approach because that’s really the appropriate setting for these children.’
 
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children and young people’s health gender-diverse health LGBTQIA+ transgender health


newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?
 
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newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?

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Dr Peter James Strickland   17/04/2024 11:41:11 AM

Lets be honest here ---trans-sexuality is rare, and not common. In 50 years of active practice I saw two true trans-sexuals, and there was zero in my group of school students of several hundred that are known. Treating teenagers with sex-changing drugs is an assault on their futures --their pituitary glands are really active and stabilising, and no-one can determine that a female is a male (and vice-versa) up to maturity. Any gender change by drugs or surgery should not happen before about 25 years old in my opinion, and no transgender male to female should be able to compete in any strength sport whatsoever as a female. Whoever is XY always remains XY, and whoever is XX remains XX. This woke opinion of treating immature humans with gender-changing hormone drugs at a young age is unethical, and should never be part of our practice. DO NO HARM!


Dr Bilal Ali Khan   17/04/2024 1:01:06 PM

Dr Cass's recommendations make sense. We should use these as a guide to develop/change our own recommendations . MDT involvement seems to be a very important aspect.


Dr Lise Susan Legault   17/04/2024 2:27:20 PM

It is well known that most children who go through natural puberty will desist in their desire to change their gender and will accept their biological sex. It is only natural to feel more like a woman or a man after being exposed to our natural sex hormones. Puberty blockers are started at Tanner stage 2 and will leave most children with lifelong sexual dysfunction, anorgasmia and questionable fertility. What child can consent to this? Australian doctors would be wise to consider the recommendations of the Cass review. I have a feeling most clinicians agree with me but are too afraid to say anything lest they be called transphobic. I agree we all want what is best for our patients.


Twitterlectual   17/04/2024 9:05:06 PM

How can a title be so blithely misleading?

The Cass report was a vindication for common sense after so many uncomfortable years of being bombarded with an aggressive mandate of affirmation. This mandate has been so conflated with people's moral panic and political identity that we managed to cause irreversible harm to children for the sake of our own personal reputation and image.

Teenage angst has become medicalised, and with the decade's fashion of gender neutrality, the purported cure is to irreversibly affect children who are too naive to understand the future they want with potent biological agents.

Gender neutrality isn't a historical first, nor is it inherently right or wrong. It has always come and gone in a cycle that follows fashion as much as necessity.

I do not think that a more considered, conservative approach qualifies as cruel or unethical, or even "denial." The Promethean alternative appears weak, impulsive, unwise, and more cruel in its irresponsibility.


Dr David Mahfouz   17/04/2024 10:49:51 PM

I agree with Drs Legault, Khan, and Strickland. We are taught all about non-maleficence in medical school, and prescribing such dangerous drugs with limited evidence in paediatric population goes against fundamental medical ethics.


Dr Joe   18/04/2024 6:45:58 PM

Puberty blockers are very dangerous drugs which cause irreversible changes to body which can lead to big regrets later in life. And then there is no going back. You are on the never ending road where you will be at war with your normal cells every single day of your living life.


Dr William James Hare   18/04/2024 10:13:29 PM

You cannot change your sex. You will always be XX or XY all your life however you feel, what clothes you wear, or what hormones you take or operations you have. You cannot change your sex!


Dr Angela Maree Roche   19/04/2024 11:15:53 AM

“ Health experts in Australia have warned against comparing our healthcare system to the NHS saying the findings cannot be directly compared “ This is a disingenuous statement and an attempt to minimise the reach that the Cass review had into this area. The review examined, assessed in detail and did a critical appraisal of all the international guidelines available in this area including the Royal Childrens Hospital Melbourne 2018 guidelines and the WPATH 2022 guidelines which I believe RCH now follows. “ Most guidelines have not followed the international standards for guideline development. Therefore only the Finnish (2020) and the Swedish (2022) guidelines could be recommended for use in practice. “
The Cass Review is not about “ denying treatment altogether “. “ We can do this while continuing to gather data “ - this is the decision. Puberty blockers and hormones will be available under trial conditions for exactly the purpose of informing “ future shared decision making.”


Dr Angela Maree Roche   19/04/2024 11:27:12 AM

“ Treatment “ in this area seems to have been reduced to a very reductionist medical model of drugs and surgery . If so , then fortunately or unfortunately, as medical professionals we cannot recommend a treatment model whose efficacy and safety data has not been established. The review found that neither has been established and needs to be for this model of treatment to become usual treatment for children and adolescents. Cass is also putting forward that in this complex grey area of often complex presentations “treatment “ is more than just drugs and surgery , and for some or most , may not be the answer .