Insurance cut for gender-affirming care ‘sends such a negative signal’

Anastasia Tsirtsakis

29/05/2023 4:18:47 PM

MDA National will no longer cover GPs initiating gender-affirming treatment for adolescents – a move that could impact patient wellbeing.

GP with patients.
Research suggests an extremely low prevalence of regret in transgender patients following gender-affirming treatment.

Last month, Dr Clara Tuck Meng Soo received correspondence from MDA National, one of Australia’s leading medical insurers, informing her that she would no longer be covered to initiate gender-affirming treatment for patients aged 18 and under.
‘It was very disappointing,’ she told newsGP, amid fears of its impact on the mental wellbeing of young people.
‘It is already so difficult for people to get appointments to see practitioners who actually work in this area.’
The insurance provider updated its policy, effective 1 July, earlier this month to exclude cover for claims that arise in any way out of:

  • a practitioner’s assessment that a patient under the age of 18 years is suitable for gender transition
  • a practitioner initiating prescribing of gender affirming hormones for any patient under the age of 18 years.
MDA National President, Dr Michael Gannon, told newsGP the insurer’s decision was motivated both by monitoring of developments overseas, as well as member feedback – a clinical area that comes with a level of risk that he says is difficult to price.
‘One of the problems with long tail insurance is that you might make a decision, or there might be a clinical matter that’s dealt with, and then it takes five, 10, 15, 20 years before that turns into a clinical problem,’ he said.
‘We’re talking about people who are making life changing decisions. So, our feeling is that that is a very high level of risk for an individual GP to take on their own.
‘We are worried about the risk that it presents to these individual members and, more broadly, the rest of our members. So, we’re making no … moral judgments, no ethical judgments – we’re making an insurance company decision based on our inability to price an area that we think might be high risk.’

Dr Soo, however, believes there is not enough data for the medical defence organisation (MDO) to be taking a step that the Canberra GP says is likely to have significant consequences for young people seeking to initiate treatment, who already face long wait times.
‘I actually rang up the manager at MDA National [and] … queried her as to why they were taking this step because I don’t know of any evidence around the world to show that people who are initiated on gender affirming treatment between the ages of 16 and 18 are actually more likely to engage in litigation,’ she said.
‘She admitted that there wasn’t actually enough data to have firm statistical data to say that this is a problem; her response was “Oh, well, you know, we are aware of six cases happening around the world – one of which is in Australia where matters are before the court – so we want to take pre-emptive action to protect our members”.
‘Six cases around the world? Plastic surgeons and cosmetic physicians are currently being sued left, right and centre – why don’t you stop covering them?
‘They could say that if you’re doing something like this you may have to pay a higher premium, but even then, without any data to support what they’re doing, the action comes across as being plain transphobic.’
Dr Gannon said the insurer has taken steps to increase premiums when an area of significant risk is identified, such as with neuro and bariatric surgeons in recent years. But he says gender affirmation treatment is more difficult to assess.
Reports emerged last year of a Sydney woman suing the psychiatrist who supported her gender transition to male when she was 19. However, there is robust research to indicate that regret after undergoing gender-affirming treatment is rare.
Nonetheless, Dr Gannon believes that the data on low levels of regret is unreliable, claiming it is not reflective of the current social context.
‘Now, most people with school aged children would know of at least one individual that is questioning or querying,’ he said.
‘In other words, this social issue has fundamentally changed in recent years from being one that was most uncommon to one which is widely considered by a larger group of people. And so, the data on people changing their minds in the experience we have probably doesn’t reflect the level of risk there is now with literally hundreds of teens questioning or querying their gender identity.’
Despite the policy change, Dr Gannon emphasised that GPs working as part of a multidisciplinary clinics within a hospital setting will continue to be covered in the initiation of gender affirming care.
However, Dr Soo queried why the clinical setting impacts the risk, as GPs in private practice do not make decisions around the initiation of gender-affirming therapies on their own.
‘I could refer a patient to see a private psychiatrist; I could refer a patient to see a clinical psychologist; I could refer a patient to go and see a speech therapist – that’s a multidisciplinary team. So why is that not sufficient?’ Dr Soo said.
‘As a GP, there’s potentially nothing, in terms of getting other health providers involved, that I couldn’t do in private practice that a hospital-based multidisciplinary team could do. This is all about them actually trying to outsource the risk.’
How will the change impact patients?
For Dr Soo, a transgender woman who works with LGBTQI+ communities, this is a matter particularly close to her heart. She harbours grave concerns about what this move could mean for the mental wellbeing of young people aged 16–18 who she believes will fall through the cracks.
In addition to long wait times – both in the public and private systems, due to a shortage of practitioners working in transgender health – Dr Soo says multidisciplinary gender clinics are so busy they often have to prioritise the patients they see, which tends to be those going through puberty aged 13–15.
‘They need to be seen urgently to get on puberty blockers, so they don’t develop more distressing physical changes,’ she explained.
‘If you’re a 16–18-year-old adolescent where you’ve gone through those changes of puberty already, but you now realise you’re actually transgender and need to go into treatment, they are actually on a low rank of priority and some clinics – like the clinic in Canberra – have now point blank said that they won’t accept referrals of people in that age group.
‘So, you now have a group of people who can’t be seen in a multidisciplinary clinic and MDA National saying, well as a GP, or even as an endocrinologist in private practice, you can’t initiate treatment. So, what do we do with these people for the next two years?’
Dr Soo also fears that MDA National’s decision could deter GPs and non-GP specialists from deciding to work in gender affirming care, exacerbating the shortage of practitioners in this space.
‘This just sends a signal that this area of medicine is so risky you shouldn’t do this kind of work,’ she said.
‘Whether or not MDA National intended to do that, that’s a consequence of their action.’
Under the amended policy, effective 1 July, GPs insured by MDA National will still be covered for:
  • ongoing repeat prescribing of gender affirming hormones (based on the medication regime initiated by a non-GP specialist as part of a multi-disciplinary team) 
  • prescription of puberty blockers with the expectation that the Australian standards of care and treatment guidelines for trans and gender diverse children and adolescents are complied with at all times when treating children and/or adolescents with gender dysphoria 
  • counselling and general healthcare involving a patient with gender dysphoria.  
For practitioners indemnified by their employer for their work in the area of gender transition, the MDANI policy will also continue to provide cover for the legal costs of investigations and inquiries arising from this work.
According to MDA National, the insurer anticipates that its policy changes will impact ‘well under 100’ of its members.
But where does that leave GPs like Dr Soo and her patients?
‘I’ll be moving to one of the other MDOs – and I think that’s really what all the health professionals working in this area who are with MDA National are going to do,’ she said.
‘Firstly, we think it’s really unnecessary and unfair, but apart from anything else, this sends such a strong signal about their attitude towards the transgender population – I’m not prepared to be part of an organisation like that.’
Dr Gannon says the insurer anticipates that it will lose members as a result of the change and that it will continue to consider what is a ‘very complex area’.
‘We’re obviously very interested in what our competitors decide in this area, and if it is the case that our competitors make a judgement that they don’t see risk in this area, that’s the beauty of our industry that people will be able to get a policy elsewhere,’ he said.
‘It’s perhaps important to state too though that we’ve had a lot more positive than negative feedback from our members who felt unsafe prescribing some of these hormones.
‘They felt pressured to prescribe hormones in an area that they didn’t quite understand … who feel comforted that this means – right or wrong – that this will make it easier for them to tell individual families, individual patients, that they don’t feel they have the expertise to prescribe in this complex area.’
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Dr Melita Ruth Cullen   30/05/2023 7:38:41 AM

I don't prescribe gender affirming medication without other practitioner involvement. Currently all my patients under 16yo go to the gender clinic QCH. I have 1 patient who is 16yo and wants to go on gender affirming medication. They are too old for the gender clinic at QCH, but too young for the gender clinic RBWH. I have referred this patient to a doctor who works at holdsworth house. Despite not being comfortable prescribing gender affirming medication without involvement of another doctor, I don't, however, like that choice being limited for me.

This lack of indemnity for gender affirming medication under 18yo, will impact alot of 16-18yo who are unable to access treatment, an event which can be immensely distressing. I want to be covered my MDA in the rare situation where I do prescribe gender affirming medication.
MDA thinks there are only 100 doctors this will effect. There will, however, be many more doctors who don't want their practice limited by the lack of indemnity

Dr Angela Maree Roche   30/05/2023 5:19:28 PM

Historically, the small number of children presenting with gender dysphoria were primarily prepubescent males. Since around 2015 , there has been a sharp increase in referrals of adolescent females , many with no prior history of childhood gender dysphoria. This is now the largest group presenting with gender related distress of which there is the least amount of data , particularly in relation to treatment and outcomes. ( Hilary Cass, Independent Review of Gender Identity Services. Feb 2022). This is the environment that the insurance company has made its decision. Much of the existing literature about the natural history and treatment outcomes for gender dysphoria in childhood were based on birth registered males presenting in early childhood.

Dr Sean Colin Chesson Stevens   30/05/2023 11:57:52 PM

I have been looking into my own indemnity arrangements. I've been with MDA for 25 years, but I understand that Avant will cover GPs for under-18 gender-affirming hormone therapy under their general practice categories, subject to following any applicable guidelines in place. This will definitely affect more than 100 doctors and I suspect will be enough for quite a number of people to walk.

Dr Samuel Christopher Ognenis   31/05/2023 12:37:57 AM

Will be cancelling MDA renewal.

Agree with you Dr Cullen.

Dr Lise Susan Legault   31/05/2023 8:14:26 AM

As a member of MDA, I am pleased with this decision. The vast majority of young people will desist in their desire to transition if allowed to go through natural puberty. Puberty blockers and cross sex hormones lead to infertility and impair sexual function in young people. How could a child consent to losing their fertility? I encourage Drs to listen to the stories of detransitioners which are very moving and ultimately an outcome of lack of safeguarding.
Listen to Chloe Cole a young woman who regretted her transition and double mastectomy.

Dr Catherine Anne Rolfe   31/05/2023 10:09:36 PM

Another barrier to accessing Gender Affirming healthcare. Although I only prescribe or administer GAHT to children and adolescents who have seen our local tertiary hospital Gender Service, I would definitely be leaving MDA if I was insured with them. Luckily, I’m with Avant. This change sends a signal that we should all be a bit worried about offering a supportive environment to these kids: ‘it might come back to bite you’ is the general gist. Really, there are so many new areas of medicine, rapidly evolving technologies and AI is here to stay - the singling out of Gender Affirming healthcare as the only statistically uncertain risk very certainly has a transphobic whiff about it.

Dr Angela Maree Roche   1/06/2023 5:27:22 PM

Between 2009-20019 across western paediatric gender services , the natal female to male ratio presentation changed from 1:2 to 2:1. There is much less data on this recent case mix of predominantly birth registered females presenting in early teens , particularly in relation to treatment and outcomes. ( The Cass Review). This is the reality that all doctors need to be medicolegally aware of and is reflected in MDA Nationals decision. It is a rapidly changing landscape internationally and nationally . The final Cass Report is due towards the end of this year and should be influential in adding more clarity.

Dr Angela Maree Roche   2/06/2023 11:46:56 AM

Please do not print misleading statements about regret. The evidence link for “ robust research “ was a news article which was terribly unconvincing. The National Institute for Health and Care ( NICE) was commissioned to undertake a review of published evidence for the Cass Review ( Feb 2022). Decisions need to be informed by long term data, on the range of outcomes, from satisfaction with transition through to a range of positive and negative mental health outcomes, through to regret and/or a decision to detransition. The NICE evidence review demonstrated the poor quality of these data , both nationally and internationally. The Australian College of Psychiatry has changed its guidelines in this area. We need to be up to date with this information - constantly changing.

Dr Kathleen Wild   3/06/2023 3:09:36 PM

I have also been advised that MDA will no longer provide indemnity insurance for oestradiol implants for gender affirming hormone therapy in adult transgender women. This is a trend of decision making that suggests an ideological rather than pure risk assessment approach. I will not conduct any further business with MDA.

Dr Manjula Rajaratnam   9/06/2023 10:14:37 AM

>70% of young people will desist in their desire to transition if allowed to go through natural puberty. We should be careful that we don't medically (+/- surgically) intervene and cause iatrogenic infertility, impair sexual function, and irreversible physical damage in young people.

Please listen to the detransitioner's stories: