The Victorian government is “fiercely proud” of its transgender health clinics, the state’s health minister has said in response to findings from a long anticipated review of gender-affirming care for young people in England.
Chaired by paediatrician Dr Hilary Cass, the review was commissioned by England’s National Health Service (NHS) in 2020, with the final report published in April 2024.
The review found the evidence base underpinning medical and non-medical interventions for children and young people with gender dysphoria must be improved and that the NHS should exercise “extreme caution” in prescribing masculinising or feminising hormones from 16 years old.
Australian experts, including clinicians, politicians and peak medical bodies, spoken to by Guardian Australia all said the trans and gender-diverse care provided by states and territories is substantially different from that in England, and is based on holistic, best-practice care with various levels of assessments.
Guardian Australia understands neither New South Wales or Victoria have plans to make changes to puberty blocker prescribing or accessibility as a result of the Cass review.
Victoria’s health minister, Mary-Anne Thomas, said: “Our gender clinics offer some of the most vulnerable young people in our community the support they deserve – we’re fiercely proud of the important work they do.
“We will continue engaging with trans and gender-diverse community and health service partners to ensure that trans and gender-diverse people can access the care they need.”
What the Cass review recommended
While the Cass review recommends every case considered for medical treatment should be discussed by a multidisciplinary team, Australian standards of care and treatment already include a multidisciplinary assessment of pubertal status, mental health needs, medical needs and social context.
Medical treatment is only initiated where clinically and legally appropriate, with informed consent from the young person, their carer and medical team all required. This may include prescribing puberty blockers, which can be used to delay the changes of puberty in transgender and gender-diverse youth.
The Cass review raised concerns that when puberty blockers were being prescribed within the NHS, young people, including older adolescents finished with puberty, only had to see psychologists.
In Australia, puberty blockers are seldom used for young people who have finished puberty.
The Cass review also raised concerns that puberty blockers can decrease bone density. In Australia, measures to counteract this are recommended, such as weight bearing exercises, vitamin D supplementation and calcium intake.
Associate Prof Ada Cheung, an endocrinologist with the Trans Health Research Group, said there are cases where “not providing, or delaying, wished-for and medically indicated treatment for transgender young people is emotionally distressing and is associated with poorer outcomes”.
“Doing nothing carries significant risk.”
While the Cass review found insufficient and inconsistent evidence around the impact of puberty blockers on psychosocial wellbeing, Cheung said it is important to note it found no studies which show worsening psychological functioning as a result of treatment with puberty blockers.
The Cass review did state: “clinicians agreed that puberty blockers and hormones provided an important pathway for care alongside therapeutic support”. Ensuring their safe use and considering long-term consequences is important, the review found.
Cheung said clinical guidelines elsewhere, including in Canada and Germany, support clinicians being able to confidently prescribe puberty blockers where appropriate. She is concerned the Cass review “downplays the risk of denying treatment to young people with gender dysphoria and limits their options by placing restrictions on their access to care”.
As a result of Cass’s preliminary findings, released in 2022, the NHS has banned the routine use of puberty blockers to treat children and young people who have gender dysphoria outside clinical research settings. Norway, Sweden, Denmark and Finland have taken a similar approach.
In Australia, puberty blockers are prescribed “always with individual weighing-up of the young person’s needs and wishes, and the benefits, risks and unknowns of the treatment in their personal situation,” Cheung said. It is not routine treatment.
“The UK have one single clinic with ridiculously long waiting lists with thousands who can’t access care and their approach is different to the holistic gender-affirming approach in Australia,” Cheung said.
Takeaways from the review
The Cass review highlights the importance of working with young people to explore their concerns and experiences around gender, “not to change who they are” but to “help alleviate their distress regardless of whether or not the young person subsequently proceeds on a medical pathway”, it said.
The president of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), Dr Elizabeth Moore, said it was important to make clear that being trans or gender diverse is not a mental health condition.
“RANZCP also acknowledges stigma, discrimination, trauma, abuse and assault contribute to trans and gender-diverse people experiencing higher rates of mental illness than the general population,” she said.
“Psychiatry has a role and a responsibility to help counter, prevent and protect against this.”
The vice-president of the Australian Medical Association, Dr Danielle McMullen, said a key message from the Cass review was that trans and gender-diverse young people are a very vulnerable population that requires the best care and support available.
“It is extremely important that every child who is gender-questioning has timely access to both clinical and mental health services that are multidisciplinary and responsive to their individual needs,” she said.
Issues with applying the Cass review to Australia
A spokesperson for the federal health minister, Mark Butler, said clinical treatment of transgender children and adolescents is a complex and evolving area in which longer-term evidence to inform treatment protocols is still developing.
“The clinical care pathways are different in the UK from Australia,” the spokesperson said. “The provision of public gender services to young people in Australia is led by the states and territories, who are responsible for the relevant services.”
The Cass review has been criticised by some Australian clinicians and trans health experts for having an unrealistic threshold for high-quality evidence, effectively discounting moderate-quality observational studies that were not randomised control trials, considered the gold standard of scientific research.
Randomised control trials are not always feasible or ethical to conduct, the vice-president of the Australian Professional Association for Trans Health (AusPATH), Dr Portia Predny, said. Many areas of medicine, including perinatal care and paediatric care, lack randomised control trials, she said.
“Additionally, when you have multiple observational studies looking at a particular intervention and those studies are producing similar findings, the cumulative evidence becomes compelling.”
Applying the findings and recommendations of the Cass review to the care of young people in Australia “was fundamentally flawed” because it looked specifically at the NHS system, she added.
The Queensland health minister, Shannon Fentiman, said the state’s Children’s Gender Service “is considered one of the best in the country, and continually reviews its models of care to ensure it is based off the best available evidence”.
“All trans young people deserve access to high-quality and timely healthcare and that is something we are committed to continue providing,” she said.
The NSW health minister, Ryan Park, said trans and gender-diverse healthcare is a complex and evolving practice area.
“NSW Health continues to monitor developments in the evidence to ensure the care we provide remains consistent with national and international best practice,” he said.
