Paul Smith 24 July 2024
The public was offered a rare glimpse into one of the country’s paediatric gender clinics last week.
There had been all sorts of dark allegations circulating in the media about the activities of the Queensland Children’s Gender Service (QCGS), many made by Dr Jillian Spencer, a psychiatrist who had been based at Queensland Children’s Hospital where the service operates.
She took exception to the clinic’s gender affirmation treatment philosophy, the use of puberty blockers, breast binding and, according to one newspaper report, the employment of the child’s preferred personal pronoun by clinic staff.
She also claimed children and their families were pressured, with children not properly assessed before medical treatment.
It is important to explain that Dr Spencer, who was allegedly forced out of the hospital for “transphobia” last April, was never part of the clinic itself.
Still, it was her claims that triggered the State Government to commission a review, and that review, chaired by psychiatrist and executive director of Clinical Excellence Queensland Associate Professor John Allan, resulted in last week’s lengthy report.
It carries significance, not simply because of the heavy politics and the rarity of its subject matter but because it comes three months after the earthquake of the Cass Review in the UK. Its rumbles were making global news as the Queensland report was being written up.
In the UK puberty blockers for under 16s diagnosed with gender dysphoria are now banned outside their use as experimental treatment because of the conclusions of Dr Hilary Cass, a retired paediatrician.
So the obvious question first. What was happening in the Queensland unit? What did the review find?
Did it give substance to Dr Spencer’s claims?
The answer is no.
The main theme running through its 104 pages can be expressed in a few words: the expert panel found no evidence of children, adolescents or their families being hurried or coerced into making decisions about the suggested medical interventions.
But there are subtleties.
The report tracked patients over a 12-month period to gauge whether the patients referred to the service were going to end up prescribed the puberty blockers and cross-sex hormones causing so much consternation.
It found that a third of patients were discharged after no medical intervention at all; 37% were still in the assessment phase at the end of the 12-month period; 12% were prescribed puberty blockers; and 17% were prescribed gender-affirming hormone treatment.
“Notably, 45% of the children and adolescents who had been prescribed puberty blockers were commenced on puberty blockers elsewhere (privately) but were reassessed as part of the standard QCGS assessment pathways and were deemed appropriate to continue puberty blockers,” the report said.
Two things must be stressed here.
This audit covered a very small sample; a cohort of 93 patients with a median age of 14 at the time of their first appointment.
This should be measured against the number of referrals to the service since it was set up in 2017, which, as will become clear later, runs into the thousands.
And this audit only included those patients who went through a new care model introduced at the clinic in 2023.
To the critics, the panel’s assessment will seem inadequate.
The evaluation itself said it had sourced information for the inquiry from clinical audits, incidents, complaints, compliments, service statistics, patient follow-ups, and consumer feedback.
Why didn’t the review track the treatments offered to all the patients who have been through the service? Surely there would be data?
The report provides no answer. It is simply silent. But it probably explains the report’s recommendation for resources to help the service collect more robust information on its clinical outcomes.
There are references to the Cass Review, however, no doubt because it cannot be ignored. It questioned the very basis of the standard medical intervention used by gender clinics around the world.
But reading the report, you would never quite grasp the scale of Dr Cass’s criticisms about puberty blockers whose evidential base she judged so threadbare that they could not be considered anything more than experimental.
Firstly, the review panel says somewhat obliquely it is “aware of the decisions made by NHS England in relation to gender services”.
There is no reference to the actual ban on the routine use of puberty blockers.
It notes, instead, that debate about the “validity of those decisions” is still running.
It then acknowledges — again without referring to puberty blockers by name — that the Cass Review “looked at the existing evidence to support care, which in many areas they state is variable or insufficient.”
What is the panel’s view on this hottest of hot topics?
“The panel recognises that there is now a further debate about the accuracy of these statements [the conclusions of the Cass Review] and the decisions which have been made based upon them.”
“Ultimately Cass is urging better … less opinionated research be conducted,” it continues in a way that seems to gloss over the radical implications.
Dr Cass is ultimately also saying no child or young person under 16 diagnosed with gender dysphoria should be prescribed puberty blockers.
“This research … should focus on not just the true value of medical treatment but should also ensure there is a wide range of interventions available and encourages young people’s participation in research,” the Queensland review continues.
That seems to be it on the evidence base for the medical interventions used at the service.
Critics will not be happy. But the review states its job was about determining whether the gender clinic was working under the relevant national and international guidelines — and none of those guidelines, including the WPATH guidelines and the Australian guidelines, regard puberty blockers as an experimental treatment with a flimsy evidence base.
The review was focused on “understanding the experience of young people and what is the best standard of clinical care”.
The question here is how can you focus on the “best standard of clinical care” if you do not get involved in the evidence which helps define best standard care.
But as the report makes clear in its opening pages, an extensive literature review on the care and treatment of children and adolescents was outside the terms of reference.
The Cass Review was also deeply troubled about the capacity of young people to provide informed consent to the medical treatments prescribed for them.
“Cass reasoned that the decision-making [for clinicians] in the NHS had been binary (ie, pursuing a medical pathway and ignoring other options) rather than offering a wide range of potential pathways,” the review says.
But it stressed that the Queensland gender clinic had “always provided a holistic, person-centred approach, evidenced by the comprehensive assessment and informed decision-making process”.
In a rebuttal to Dr Spencer’s claims, the review added: “The [service] takes into consideration other issues affecting the young person, for example parental loss, traumatic illness, diagnosis of neurodiversity, isolation or bullying in school and the presence of mental illness.”
It also added this: “The informed consent process and the information contained within the consent forms for the commencement of puberty blockers and gender-affirming hormones is comprehensive and considers the capacity of the child or adolescent and their family to provide informed consent.”
And again: “The process of making decisions about medical intervention is thoughtful, considered and evidence based.
“The panel found no evidence of children, adolescents or their families being hurried or coerced into making decisions about medical intervention.”
Beyond this, the other substantive finding of the review was the enormous pressure staff at the clinic are under and have been under for some time.
There are graphs and bar charts documenting the increasing number of referrals made to the service over the last seven years.
For instance, between March 2019 and December 2022, it received 2497 referrals from GPs alone.
“By the end of 2022, the service was experiencing exceptional demand for its services to children and adolescents with diverse gender experiences,” the report says.
“With an active clinical caseload of over 900 patients, the service found itself grappling with the challenge of providing extended, and often complex care to many individuals, thus straining the capacity of the workforce to accommodate new patients from the waitlist.
“The waitlist continued to grow, with nearly 700 patients waiting, and an average of 54 new referrals being accepted and added to the waitlist each month.”
It said nearly 500 patients on the waitlist had exceeded the recommended waiting time frame by this point.
Staff, dealing with complex presentations in a vulnerable cohort at a time when the debates about the rights and wrongs of what they are doing is toxic, have suffered.
The escalating demands on them explains the decision by the service’s clinical leadership team to change the service model and introduce a new service delivery framework in 2023.
The main approach now is a triage system — with category 1 patients seen within 30 days, category 2 within 90 days and category 3 within 365 days.
The report is worth reading for those who think the patients are on some kind of conveyor belt of care with no options but to sit still or jump off.
It documents in detail what clinicians and staff at the service do in terms of assessment and support.
Take, for example, the care pathway for children and adolescents aged 8-15.
The report says the young person and their family will attend the Single Session Therapy — Family session with a mental health practitioner.
A clinical intake review team will then determine if the child or adolescent requires further comprehensive assessment or whether they should be discharged back to local services.
The comprehensive assessment, when it happens, involves a biopsychosocial assessment with senior mental health practitioners and relevant members of the multidisciplinary team.
It covers mental health risk assessment, gender assessment, physical health screening and a neurodevelopmental/cognitive assessment.
Then there is a review meeting to discuss possible approaches ranging from continuing the assessment with possible referral to psychiatry, provision of non-medical support for gender dysphoria, medical treatment for gender dysphoria, or discharge.
“If a child or adolescent is progressing to medical treatment, they will be referred to the paediatric endocrinologist, sexual health physician, GP with Special Interest or Adolescent and Young Adult registrar.”
The main recommendation is for the Queensland Government to immediately increase medical, nursing, allied health and admin staffing to meet the “urgent clinical needs within the waitlist”.
The second element is for the creation of a statewide network of services, with the Queensland Children’s Gender Service functioning as a tertiary centre for the escalation of complex clinical cases.
Following the report’s release, Dr Spencer was approached by the media.
The review panel was “stacked” with “hard-line gender clinician activists” who had established links to the gender clinic, she was quoted as saying.
“The panel predominantly consulted with gender affirming clinicians and organisations with established links to the gender clinic,” she said.
“The chair of the panel was a Queensland Health employee and so the report was not an independent report as claimed.”
No, she was not happy.
The review, for her, never went deep enough, something which would mean going to the very foundation of the clinical guidelines itself.
Read more:
- Why detransition became an untouchable subject in gender care: special report
- How many patients re-identify with their birth-registered sex? Rare findings from an Aussie gender clinic
More information: Queensland Health: July 2024