Lessons to draw from the Tavistock report

Criticisms of gender dysphoria treatment in the UK do not apply to Australian practice.

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London’s Tavistock gender identity clinic has hit international headlines again, amid renewed legal threats from former patients.

Australian doctors treating children with gender dysphoria have little to fear, however.

Many of the specific criticisms levelled at the Tavistock, while presented by some outlets as an indictment of gender clinics as a concept, don’t apply to Australia’s model of care.

By far the biggest criticism levelled at the Tavistock has been that puberty blockers were prescribed over-liberally.

A recent independent review called the practice “arguably more controversial than the administration of the feminising/masculinising hormones”.

The medicines are commonly prescribed off-label to transgender children in the UK, Australia, America and Scandinavian countries, to temporarily delay the onset of puberty.

The way in which the Tavistock clinic was prescribing puberty blockers significantly diverged from internationally accepted best practice.

The NHS mandates that anyone under the age of 18 who wants to access cross-sex hormones must be on puberty blockers for at least 12 months.

At times, the Tavistock centre had a waitlist of years. The longest someone was on the list was four years, according to a response to a Freedom of Information request.

This meant that children referred at nine or 10 years of age often didn’t get seen until they were in late puberty or had finished pubertal development.

They were given puberty blockers regardless; this is not standard practice in Australia.

“Using puberty blockers in such individuals is more likely to induce unwanted menopausal symptoms such as fatigue and disturbed mood,” a team of Australian clinicians wrote in a BMJ editorial.

“For these reasons, puberty suppression outside the UK is typically reserved for gender-diverse young people who are in early or middle puberty, when there is a physiological reason for prescribing blockers.”

Another specific criticism related to puberty blockers at the Tavistock was that they were often prescribed too fast, after just one or two consultations.

Again, this is not necessarily an issue in Australia.

The Royal Children’s Hospital in Melbourne, which runs an internationally regarded gender clinic and research arm, already uses a multidisciplinary team model, with a strong emphasis on supporting the mental health of young people referred to its service.

“Pharmacological treatment is only offered after comprehensive multi-disciplinary clinical assessment (including medical and psychological assessment) and only with the full support of the young person, their treating clinicians and their parents or legal guardians,” a hospital spokesman told The Medical Republic.

“Importantly, our gender service is underpinned by established research methodology to monitor outcomes that will continuously inform best practice.”

Australian Professional Association for Trans Health president Dr Fiona Bisshop acknowledged that there were broader concerns around the use of puberty blockers for transgender children.

“People are absolutely correct in that we don’t have long-term data [on puberty blockers for gender dysphoria], and we do need long-term data,” she told TMR.

“But you can’t collect long-term data if you don’t actually put people on puberty blockers, and it’s going to take a long time for that data to appear.”

In the meantime, Dr Bisshop said, there is a wealth of data on the positive short-term outcomes for young people who go onto blockers.

Another significant difference in Australia’s approach to managing gender dysphoria in young people is how the system is set up.

In the UK, the London-based Tavistock centre was the only clinic providing care for transgender youth.

Dr Hilary Cass, the independent reviewer appointed by the NHS to investigate what went wrong at the Tavistock, recommended in her interim report that the gender service be decentralised.

“In my interim report I said that a single specialist provider model is not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand,” she said.

“The purpose of the regionalised model is to improve access, networked care, research capacity and workforce development.”

Multiple states in Australia have already moved away from the single-centre approach, and for good reason.

“A number of states in Australia have taken steps to decentralise [gender services] and to have more regional, multidisciplinary clinics to do assessments for young people,” Dr Bishop said.

“That was partly driven by the blowout of waiting lists, but it also just makes a lot more sense to be able to not have to travel to a capital city to be assessed when it’s such a common issue.”

Ultimately, Dr Bisshop said, the Tavistock closing down shouldn’t be seen as a justification to shut down all gender clinics, but as a portrait of the UK’s broken system.

“This is being portrayed as a failure of gender clinics, and it’s being portrayed as ‘gender clinics are dangerous and to be closed down’,” she said.

“What the message should be is that we need to make gender clinics fit for service, and having a central model that has a five-year waiting list is not the way to do that.”