Two countries, two reviews into care for young people with gender dysphoria and two very different outcomes.
Stop us if it sounds familiar: following allegations of rushed treatment, an independent panel of experts is appointed to take a deeper look at a hospital-based clinic providing young people with gender-affirming care.
The resulting review paints a picture of a clinic facing internal and external pressures that is not necessarily meeting the needs of its patients.
But here’s the twist: instead of making recommendations which have the effect of restricting gender-affirming care further, the review recommends expanding gender services and investing in more staff.
Within days of the report’s release, the government doubles the funding going toward gender services.
That’s what happened in Queensland last month, contradicting the state’s reputation as a laggard on progressive social justice issues.
The independent review, which was spurred by complaints from a staff psychiatrist, found that the Queensland Children’s Gender Service provided safe, evidence-based care consistent with national and international guidelines.
All told, around one third of the young people assessed by the service were discharged and connected with community-based services, a third underwent further management and the final third were prescribed puberty blockers or gender-affirming hormones.
The review also identified “considerable stress” within the clinic due to understaffing and long waitlists, as well as broader cultural issues contributing to stigma around its patients.
Among the key recommendations were that the state government should immediately hire more staff, build new data collection systems and establish a bigger network to deliver services more evenly across the state, rather than having it concentrated at the Queensland Children’s Hospital in central Brisbane.
All recommendations were accepted.
The Queensland review just so happened to be released within months of the United Kingdom’s independent review of gender identity services for children and young people.
It’s better known as the Cass Review, in reference to chair Dr Hilary Cass.
Its publication was a big part of why England introduced regulations restricting the prescription and supply of puberty-blocking hormones as a treatment for gender dysphoria in people under the age of 18. This was seen by many as a move to limit care.
Here’s the thing: the findings of the Cass Review weren’t dissimilar to the findings of the Queensland team.
Even Queensland panel chair Associate Professor John Allan drew the connection.
“The panel actively considered the findings and ultimately made a number of recommendations that were aligned with the Cass Review findings, particularly in reference to a networked approach to care; appropriate data collection and linkages to research; and improving health worker expertise and understanding of diverse gender experiences to enable expanded service options,” he said.
So why has the effect in Queensland been an expansion to gender-affirming care, while the effect in the UK been a contraction?
Multiple experts agree that it comes down to the different ways in which evidence was used.
According to Brisbane GP Dr Fiona Bisshop, immediate past president of the Australian Professional Association for Trans Health, the Cass Review largely ignored doctors who were providing gender-affirming care.
“There have been multiple expert academic treatises written on what was wrong with the Cass Review … they intentionally sidelined people who worked in the field,” she told The Medical Republic.
“Practitioners who worked with trans patients and trans people themselves were excluded from that whole review, and that didn’t happen [in Queensland].
“They talked to the right people who were using the service and they also included some people in the review panel who were experts.”
Dr Bisshop rejected criticism that framed the involvement of doctors who practised gender-affirming care as biased.
“If you were reviewing a neurosurgical service, you’d need to have some neurosurgeons on the review panel,” she said.
“You don’t put faith healers on it.
“You have to have people who understand how it works.”
Victorian GP Dr Michelle Dutton, who also works with young people experiencing gender dysphoria, independently echoed Dr Bisshop’s words.
“The Cass Review reflects the political climate of the UK as much as it does any kind of objective review of the evidence,” she told TMR.
“The British Medical Association is now doing a review of the Cass Review because of concerns about the way that evidence was selected and analysed.
“It really highlights the fact that the Cass Review was about care in the UK and the way their health system was structured, whereas our health system is set up very differently.”
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One of the bigger issues with the Cass Review was the unbalanced way it treated evidence, according to Australian epidemiologist and writer Gideon Meyerowitz-Katz.
“There’s a very careful, scientific and extremely sceptical review of the evidence that supports the gender-affirming care narrative or that supports medicalisation to some extent, but things that go against gender-affirming care or medicalisation are given a free pass throughout the review,” he told TMR.
Of the three systematic reviews from the University of York commissioned by the Cass Review, for instance, the one focused on psychosocial and psychological interventions inexplicably used a different methodology.
“They overtly applied a different standard of evidence to psychosocial and social intervention than they do medical intervention,” Mr Meyerowitz-Katz said.
“And they don’t give any reason why you don’t need good evidence to support these interventions – and those are now the only interventions that are legal for use in [children with gender dysphoria in] the United Kingdom.”
