Are gender affirming treatment guidelines high quality?

Written By Bel H

In Australia, there are no government-commissioned treatment guidelines for gender-affirming care (although one guideline is more widely utilized than others).

While several treatment guidelines are used throughout Australia, the quality of their recommendations has been called into question, and there are very few limitations on access to gender-affirming care.

WHO CAN ACCESS GENDER AFFIRMING CARE?

Affirming Guidelines: Background & Concerns

Background information and controversies concerning other notable guidelines used in Australia are in the drop down list below.

THE RCH GUIDELINES

Most Australian gender services are modeled on the Melbourne Royal Children’s Hospital’s Australian Standards of Care and Treatment Guidelines (for children and adolescents) - often called the RCH guidelines. These guidelines:

  • Recommend gender affirming care, a model that discourages thorough psychological evaluation before diagnosis or treatment. 
  • Promote puberty blockers, cross sex-hormones, and surgery with no set age-limits. 
  • Advise that: “...decision making should be driven by the child or adolescent wherever possible, and this applies to options regarding not only medical intervention but also social transition". 
  • Are not government-commissioned, weren't assessed by Australia’s National Health and Medical Research Council, and have received significant criticism since their publication. 
  • Have a limited evidence base supporting their recommendations, and are influenced by controversial guidance from the  World Professional Association for Transgender Health (WPATH).
  • In 'A History of Trans Health Care in Australia', the medico-activist group the Australian Professional Association for Trans Health (AusPATH) acknowledges that WPATH’s guidelines provide “a form of liability protection for health professionals working in trans health care because they could point to the standards of care as guiding their practice” and, “an air of legitimacy in an area of health care which was, for decades, looked down upon by much of the medical profession.”
  • Despite the serious limitations of the RCH,guidelines, their lead author Dr Michelle Telfer, told a 2022 parliamentary inquiry that they had become, “accepted as the current gold standard care for Australia and is used as such across the country."

  • "The title is actually misleading" Researchers in the field have raised concerns that the title of the Guidelines - ‘Australian Standards of Care and Treatment Guidelines’, may overstate the document's authority and level of government endorsement. Elkadi et al, have pointed out:

    "The title is actually misleading. In Australia there are no official or authorized government-commissioned standards for assessing or treating gender dysphoria."

    Given this, and their limited consultation, the RCH guidelines are probably more accurately described as a position statement.

    Limited consultation: Treatment guidelines are typically developed through wide consultation and reflect a general medical consensus.

    In contrast, the RCH guidelines were developed by just four clinicians, all of whom were affiliated with Melbourne's Royal Children's Hospital and its research partner, the Murdoch Children’s Research Institute.

    Conflict of interest: The RCH guidelines are endorsed by medico/advocacy group, the Australian Professional Association for Trans Health (AusPATH).

    The guideline’s lead author, Dr Michelle Telfer held leadership roles at AusPATH on the following dates:

    • 2012 - 2022: Head of the Royal Children's Hospital Gender Service

    • 2014 - 2018: Executive Member & Vice President

    • 2018 - 2020: AusPATH President

    Low Quality: The RCH guidelines did not qualify for assessment for the National Health and Medical Research Council’s Australian Clinical Practice Guideline portal. According to the NHMRC:

    "It was determined that the guideline did not include a funding statement, an evidence base for the recommendations or information about conflict of interest, and that it would not meet the portal selection criteria, so a full assessment was not carried out." - Reported by Bernard Lane for The Australian

    There is a lack of transparency about the NHMRC’s decision. Only one version of the RCH guidelines, published in the Medical Journal of Australia, includes the following statement:

    “The scarcity of high-quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations.”

    This acknowledgment can’t be found in the version of the guidelines promoted on the RCH website.

    In 2019, a critique of the RCH guidelines, published in the prestigious medical journal The Lancet argued that:

    “The health of transgender children is addressed with imprecise language and overplayed empirical evidence in new Australian guidelines.”

    In 2021, a review by The Society for Evidence-Based Gender Medicine (SEGM) found that AusPATH relies on poor-quality research, and misrepresents or exaggerates research findings.

    In 2023, the RCH guidelines were found to be "untrustworthy" by an expert in rating evidence-quality from McMaster University in Canada.

    In a systematic review of international guidelines, commissioned by the UK's National Health Service for the Cass Review, the RCH guidelines scored just 19/100 for their rigour of development and 14/100 for independence.

    False consensus & circular referencing: The same systematic review also uncovered a concerning pattern of circular referencing between international treatment guidelines, including the RCH guidelines and influential WPATH and Endocrine Society' guidelines.

    These guidelines frequently cite each other as sources of authority, mutually reinforce one another's recommendations and arguably, have constructed a false consensus. The review’s author Dr. Cass has said:

    “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

    The RCH guidelines were Influenced by World Professional Association for Transgender Health (WPATH). In A History of Trans Health Care in Australia, AusPATH acknowledges that WPATH’s guidelines provide “a form of liability protection for health professionals working in trans health care because they could point to the standards of care as guiding their practice” and, “an air of legitimacy in an area of health care which was, for decades, looked down upon by much of the medical profession.”

    Out of date: A substantial body of new research, data, and insights on gender affirming care has emerged since the publication of the RCH guideline in 2019. However, the current version of the guidelines still don't incorporate any references dated after 2018.

    The RCH guidelines do not address the frequency or potential risks associated with detransition or transition regret: A single mention is made of individuals who "later socially transition back to their gender assigned at birth," however, the guidelines don't integrate the growing body of evidence about experiences of medical detransition or transition regret.

    Recommendations may not be in line with current legislation: Because the RCH guidelines haven't been approved by Australia's National Health and Medical Research Council (NHMRC), changes can be made to the guidelines without regulatory oversight.

    In 2023, changes to the guidelines expanded the role of General Practitioners (who usually do not have specialised training in gender-affirming care), to initiate hormonal treatments for minors. It's been reported that these changes were carefully worded to prevent medical insurers denying practitioners coverage.

    The 2022 Informed Consent Standards (also endorsed by AusPATH and not endorsed by the NHMRC) echoed these changes, permitting GPs to prescribe hormones, seemingly without a specialist mental health assessment where ‘not indicated’.

    The legality of prescribing gender-affirming hormones to minors without a formal diagnosis or specialist involvement has been questioned:

    Legal and medical experts have suggested that such practices may not align with established standards set by the Family Court of Australia.

    Patrick Parkinson AM, Professor of Law at the University of Queensland and Dr Philip Morris AM, President National Association of Practicing Psychiatrists, have argued that decisions made by the Family Court place constraints on the provision of hormone treatment to adolescents:

     “First...a formal diagnosis of gender dysphoria is required before prescribing hormonal therapy to any child aged under 18 years.

    "Second, as the majority judgment indicated in Re Kelvin, what the Family Court has now authorised is treatment in accordance with established guidelines. Invariably, these guidelines require the involvement of a multidisciplinary team.

    "Third, treatment of those under 18 years of age cannot occur if either parent disagrees with the assessment of the child’s competence to consent, the diagnosis of gender dysphoria or the treatment plan. If the treating doctors disagree, the case also needs to be referred to the court.

    "Failure to comply with these requirements means the treatment is unlawful, and the medical practitioner is exposed to significant legal risk."

    Out of step with other guidance: The RCH guidelines present ‘gender affirming care’ as the only acceptable treatment path, but this is at odds with position statements from the Royal Australian and New Zealand College of Psychiatrists and the Australian National Association of Practicing Psychiatrists, both of which emphasise the role of psychological support as a first-line treatment.

    The RCH guidelines discourage differential diagnoses and falsely equate psychological exploration with conversion therapy practices. They say:

    "Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.

    "In the past, psychological practices attempting to change a person’s gender identity to be more aligned with their sex assigned at birth were used. Such practices, typically known as conversion or reparative therapies, lack efficacy, are considered unethical and may cause lasting damage to a child or adolescent’s social and emotional health and wellbeing."

    The RCH guidelines do not endorse or describe a specific diagnostic/assessment process: They only suggest that clinicians use DSM-5 criteria for Gender Dysphoria, or ICD-10 codes.

    Australian clinics do not have a standardised diagnostic process for gender dysphoria.  

    Language used in the RCH guidelines is often vague, inaccessible or biased towards particular outcomes:

    The guidelines:

    • Make frequent use of ambiguous and subjective terminology, such as Gender identity, Gender diversity or Gender fluid:

      For example: "Being transgender is one way of being gender diverse, but not all gender diverse people are transgender."

    • The guidelines mislead or fail to fully inform readers about the medical significance of biological sex:

      The guidelines don't define male, female or biological sex. The phrases ‘assigned male/female at birth are used instead.'

      ‘Assigned male at birth' is defined as: “A person who was thought to be male when born and initially raised as a boy." This definition obscures the immutability and ongoing medical significance of biological sex. Arguably, this description is more closely aligned with that of someone born with a Disorder of Sexual Development, whose sex was initially recorded incorrectly, than with a trans person.

    • The guidelines also provide recommendations for “Commencing oestrogen for induction of female puberty” in males. Female puberty is genetically pre-programmed in natal females and involves the production of endogenous same-sex hormones. Consequently, it is impossible to induce a female puberty in a male patient, and vice-versa.

    • The guidelines contain contradictory recommendations and language:

      For example: they describe hormonal treatments as being "partially irreversible."

      Or for example, they argue that gender dysphoria requires medical intervention, but also, that it isn't a medical condition.

    • The guidelines promote an unhealthy fixation on gender stereotypes:

      For example, they recommend supporting children to socially transition, which they say:

      "...may include changing one’s preferred name and pronouns, hairstyle, or wearing clothing that is stereotypically associated with the gender one identifies with."

      Against established advice on communicating about body image, the guidelines encourage an association between certain characteristics, such as a person's breasts, or the sound of their voice, with masculine or feminine ideals:

      "Breast binding or breast augmentation via padding can assist in masculinising or feminising the appearance of one’s chest."

    • And: "[The role of a speech pathologist may include] Teaching efficient voice production focusing on gender specific characteristics and listener perceptions."

Other guidelines used in Australian clinics

  • The Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy, 2022 (ICS) outline gender affirming treatment protocols for people under 18 and adults.

    The ICS were developed by AusPATH, the same organisation that endorsed the RCH guidelines. Like the RCH guidelines, the ICS don’t have National Health and Medical Research Council approval:

    As of 2023, the ICS were being promoted for use by General Practitioners:

    • According to the ICS, the guidelines aim to enable patients to:

      “…access hormone therapy with their clinician, without endocrine or mental health specialist consultations where not indicated.”

      And:

      “All doctors can be a gender affirming doctor.”

    • Some organisations, such as Transhub also advise that under Informed Consent models, accessing medical gender affirmation doesn’t require a diagnosis of gender dysphoria:

    • The accuracy and legality of this advice have been questioned (See: The Age).

    The Informed Consent Standards do not describe gender dysphoria or gender incongruence but they do reference a position statement, Hormone therapy for trans and gender diverse patients in the general practice setting, a ‘practical guide’ to gender-affirming hormone therapy for General Practitioners.

    This position statement advises:

    “Depression and anxiety are common in the TGDNB population and are not a contraindication to the commencement of gender-affirming hormones.

    “Before initiating gender-affirming hormones, it is important to confirm a history of gender incongruence.

    “This is self-determined by the patient.”

    The ICS also say:

    “…it is important to avoid pathologising the trans experience; being trans is not a mental illness.”

    And:

    “Informed consent models of hormone prescribing resist the notion that a doctor can determine the validity of a person’s gender, and instead centre the trans person in the decision-making process,”.

  • The Framework for the Specialist Trans and Gender Diverse Health Service for People, Under 25 Years (2023)

    In 2023, over 35 psychiatrists, psychologists and doctors wrote an open letter to NSW parliamentarians expressing “serious professional concerns” about the state’s affirming framework for gender treatment and its recommendations for the use of puberty blockers and hormones:

    "This flawed framework disregards the more cautious model of treating childhood and youth gender dysphoria adopted by countries such as the United Kingdom, Sweden, Norway, Finland and France...the framework also makes claims in support of puberty blockers and cross-sex hormones for children and young people that have been disputed or have a weak evidence base."

    In a 2024 paper, Evolving national guidelines for the treatment of children and adolescents with gender dysphoria Kozlowska et al, wrote:

    “The [NSW] framework notes (p. 2) (NSW Ministry of Health, 2023) that it was also informed by a 2020 “evidence check” by the “Sax Institute” (Sax Institute, 2020), an independent research and policy organization. Notably, the institute had actually concluded that the evidence base for puberty blockers and cross-sex hormones was not only small but, overall, of low quality. This conclusion is not mentioned, however, in the NSW framework, nor are the conclusions of recent systematic reviews (Brignardello-Petersen and Wierchioch, 2022; Ludvigsson et al., 2023; NICE, 2020a, 2020b; Pasternack et al., 2019; SBU, 2022).”

  • The World Professional Association for Transgender Health, WPATH, Standards of Care, Version 8, 2022

    The WPATH SOC 8 forms the basis of treatment protocols internationally, including those used throughout Australia.

    In recent years, several controversies have revealed the activist driven and anti-scientific underpinnings of WPATH’s recommendations. In 2022, The WPATH, SOC-8:

    • Withdrew a draft chapter on ethics from publication.

    • Removed all age limits for hormonal and surgical treatments.

    • Most incredibly, the SOC-8 introduced a chapter on 'eunuch identities', which was later revealed to have been influenced by members of an online fetish site. The unbelievable chapter and its origins are described by the Alabama Attorney General’s amicus brief in United States v. Skrmetti:

      "As if to drive home how unscientific the SOC-8 enterprise was, WPATH included an entire chapter on “eunuchs”—“individuals assigned male at birth” who “wish to eliminate masculine physical features, masculine genitals, or genital functioning.

      “Because eunuchs “wish for a body that is compatible with their eunuch identity,” WPATH recommends “castration to better align their bodies with their gender identity. That’s not an exaggeration.

      “When asked at his deposition whether “in the case of a physically healthy man with no recognized mental health conditions and who presents as a eunuch seeking castration, but no finding is made that he’s actually at high risk of self-castration, nevertheless, WPATH’s official position is that that castration may be a medically necessary procedure?”, [lead author]  Dr. Coleman confirmed: “That’s correct.

      “Coleman also admitted that no diagnostic manual recognizes “eunuch” as a medical or psychiatric diagnosis. And other SOC-8 authors criticized the chapter as “very high on speculation and assumptions, whilst a robust evidence base is largely ab- sent.

      “[Co-author] Dr. Bowers even admitted that not every board member read the chapter before approving it for publication. No matter: The guideline the United States says States must adopt officially recommends castration for men and boys who identify as “eunuch.

      “And how did WPATH learn that castration constitutes “medically necessary gender-affirming care”? From the internet—specifically a “large online peer- support community” called the “Eunuch Archive.

      “According to SOC-8 itself, the “Archive” contains “the greatest wealth of information about contemporary eunuch-identified people. The guideline does not disclose that part of the “wealth” comes in the form of the Archive’s fiction repository, which hosts thousands of stories that “focus on the eroticization of child castration” and “involve the sadistic sexual abuse of children.

      “The fictional pornography” “includes themes such as Nazi doctors castrating children, baby boys being fed milk with estrogen in order to be violently sex trafficked as adolescents, and pedophilic fantasies of children who have been castrated to halt their puberty.

      “Despite all this, the medical interest groups supporting Petitioner still claim that the WPATH guide- line “follow[ed] the same types of processes … as other guidelines promulgated by amici and other medical organizations.”

    In 2024: Leaked internal files from WPATH lent support to widely-held doubts about the ethical and scientific basis for their recommendations. The leaked documents included:

    • Transcripts of WPATH members acknowledging that children have difficulty giving informed consent to affirming procedures because it is, “out of their developmental range to understand the extent to which some of these medical interventions are impacting them.”

    • Reports from WPATH members of their patients feeling “brainwashed” into transitioning and frequent occurrences of regret.

    The independence and reliability of WPATH’s guidelines have also been called into question by a 2024 systematic review of treatment guidelines:

    The review unconverted a concerning pattern of circular referencing, whereby international gender affirming guidelines frequently cite each other as sources of authority, contributing to a false sense of consensus. The author of the review, Dr. Cass has said:

    “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

    Additionally, in a paper prepared for the Federal Circuit and Family Court of Australia, barrister Belle Lane has written:

    "Critics have raised concerns about the same clinicians being involved in the development of the Dutch protocol, WPATH Standards and Endocrine Guidelines. The concern is that each group’s development of their clinical recommendations and affirmation of the other’s approach is not truly independent."

    "Arguably, these concerns are relevant to Australia with the connections between the authors of the Australian Standards, RCHGS and AusPath."

  • The South Australian Statewide Gender Diversity Model of Care (2023)

    In a 2024 paper, Evolving national guidelines for the treatment of children and adolescents with gender dysphoria Kozlowska et al, write:

    “The SA model of care mentions the interim Cass report (Cass, 2022), the evolving nature of the evidence base, and the changing nature of overseas models of care, but it does not include any evidence-based information from systematic reviews published from around the world (Government of South Australia, 2023”.

  • The Equinox guidelines Protocols for the Initiation of Hormone Therapy for Trans and Gender Diverse Patients, 2020 were first produced in 2017 by Equinox, a peer-led Trans and Gender Diverse Health Service.

    It's difficult to know how widely used the Equinox guidelines are but, like other guidelines, they have not been approved by the NHMRC. They have been endorsed by AusPATH,

    The Equinox guidelines were the first Australian guidelines to offer the Informed Consent model, a model that dramatically reduces barriers to Gender Affirming treatments.

    The Equinox guidelines contain no references.

Bel H