Is there medical consensus on the efficacy and safety of Gender Affirming treatments?
There is no medical consensus on the efficacy, safety or ethics of Gender Affirming treatments such as puberty blockers, cross sex hormones or gender affirming surgeries. The timeline below contains a selection of concerns and warnings issued by the Australian medical community and international health bodies in recent years.
As of November 2024, The UK, Sweden and Finland had banned or placed tight restrictions on puberty blockers and cross sex hormones for minors. Medical bodies in Australia, the USA, Norway, Denmark, Italy and France had also raised concerns about the treatments.
Lack of consensus - a timeline
September 2024: 46 doctors signed an open letter calling for an 'Evidence Check' into Gender Affirming Care commissioned by the NSW Government, to be "publicly retracted as false/and or misleading."
The open letter stated that the 'Evidence Check’ contained “scientifically unsupported assertions that puberty blockers are reversible”, and “did not include the highly relevant systematic reviews and finding of the Cass Review."
September 2024: The Chilean Ministry of Health recommended that the public and private care providers the initiation of new treatments with puberty blockers and cross hormones for children and adolescents. According to Chilean media, in the future children will be provided with professional psychosocial support to the child.
June 2024: The American College of Pediatricians authored the Doctors Protecting Children Declaration in which it called on prominent American medical institutions to halt current harmful protocols promoted for children and adolescents who express discomfort with their biological sex. The declaration has been co-signed by medical and health organizations from across the U.S.
May 2024: The German Medical Assembly, representing 17 medical associations, passed a resolution calling on the Federal Government to restrict puberty blockers, cross-sex hormones, and transition surgeries for under 18's to controlled clinical trials. The resolution cited the absence of reliable evidence for youth transitions and the long term health risks of transition, including impaired reproductive function.
May 2024: The UK Government introduced emergency legislation placing an indefinite ban on new prescriptions of puberty blockers for minors. According to the National Health Service puberty blockers may be prescribed to children who are participating in clinical research.
April 2024: Scotland's only gender clinic announced a pause on referrals of prescriptions for puberty blockers and cross-sex hormones to people under 18. In a statement, the clinic said the change was in response to research from NHS England and the Cass Review, both of which found little evidence supporting the treatments.
April 2024: The European Society for Child & Adolescent Psychiatry (ESCAP) advised recent reviews of trans medicine highlighted that research on treatment benefits and harms of significant flaws, that the evidence for the benefits of these treatments is very limited. In a communication, ESCAP went on to say:
"ESCAP calls for healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psycho- social effects and, therefore, to adhere to the "primum-nil- nocere" (first, do no harm) principle."
April 2024: The Cass Review, an independent review of the UK's gender identity services for children and young people, found that gender medicine was an area of "remarkably weak evidence" that had been exceptionalised to the detriment of children treated at gender clinics:
"Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better."
March 2024: England's National Health Service confirmed that children will no longer routinely be prescribed puberty blockers at gender identity clinics. The NHS's new policy stated:
“We have concluded that there is not enough evidence to support the safety or clinical effectiveness of [Puberty suppressing hormones] to make the treatment routinely available at this time.”
March 2024: Leaked internal files from global transgender healthcare body WPATH lent support to widely-held doubts about the ethical and scientific basis for the medical transitioning of children. 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 patients feeling “brainwashed” into transitioning and frequent occurrences of regret.
January 2024: A World Health Organisation FAQ into the development of guidelines on the health of trans and gender diverse people reported that, "on review, the evidence base for children and adolescents is limited and variable regarding the longer-term outcomes of gender affirming care for children and adolescents."
December 2023: The Royal Australian and New Zealand College of Psychiatrist’s updated position statement recognised the lack of evidence for the medical transitioning of minors and stressed the importance of exploratory therapy:
"Distress associated with gender may in some situations be related to a range of psychosocial issues or mental health conditions".
October 2023, Dr Riittakerttu Kaltiala, an adolescent psychiatrist who pioneered the establishment of an early clinic for gender-distressed youth in Finland appeared in the article: Gender-Affirming Care Is Dangerous. I Know Because I Helped Pioneer It. In the article, Dr Kaltiala told The Free Press:
"It is devastating to speak to patients who say they were naive and misguided about what transition would mean for them, and who now feel it was a terrible mistake. Mainly these patients tell me they were so convinced they needed to transition that they concealed information or lied in the assessment process."
November 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."
August 2023: The Journal of the Danish Medical Association, confirmed that the country had shifted away from prescribing puberty blockers and cross-sex hormones to minors. The Association noted a lack of evidence supporting the model and the rates of detransition:
“The Danish clinicians are now concerned that the basis for gender-transition of large numbers of minors with diverse presentations of gender dysphoria is a single short-term Dutch study based in a different population and which has failed replication outside the Netherlands.” (SEGM Summary)
July 2023: The Medical Director of Child and Youth Mental Health Services, Children's Health Queensland Dr Stephen Stathis told a conference that he had changed his mind about the use of puberty blockers for minors and that the evidence based for their use was of “low quality”.
July 2023: Australian medical indemnity insurer MDA announced it would restrict coverage for private doctors who perform gender affirming hormones on minors. In a press release explaining its decision, MDA cited growing criticism of current treatment practices, the risk of “high-value claims arising from irreversible treatments", and the possibility that doctors may be held liable for influencing patient decisions:
“…there is growing criticism globally of the research that underpins medical and surgical transition of children in response to gender dysphoria.”
June 2023: Dr. Jillian Spencer, a child and adolescent psychiatrist warned that most clinicians held serious concerns about the Affirmation Model but are being '“forced to affirm the social transition of all children.”
“I would say that the vast majority of child and adolescent psychiatrists hold very serious concerns about the affirmation model but to speak up in the current climate or even to take a more cautious clinical approach puts their employment at risk, their AHPRA registration is at risk and they fear criminal sanctions under the conversion therapy legislation.”
March 2023, the Norwegian Healthcare Investigation Board recommend restricting the use of puberty blockers, cross-sex hormones and transition-related surgery to clinical research settings (note: these were recommendations, not a formal ban). The board also recommended that these treatments should be defined as experimental.
February 2023: A former employee of the Washington University Pediatric Transgender Center filed an affidavit alleging serious medical negligence and harm to patients. In a 23 page testimony, the employee alleged:
"I personally witnessed Center healthcare providers lie to the public and to parents of patients about the treatment, or lack of treatment, and the effects of treatment provided to children at the Center. I witnessed staff at the Center provide puberty blockers and cross-sex hormones to children without complete informed parental consent and without an appropriate or accurate assessment of the needs of the child. I witnessed children experience shocking injuries from the medication the Center prescribed. And I saw the Center make no attempt or effort to track adverse outcomes of patients after they left the Center."
January 2023: The Italian Psychoanalytic Society wrote to the Italian Prime Minister Giorgia Meloni expressing serious concerns about the use of puberty blockers on children. In an open letter, the IPS also warned that a diagnosis of gender dysphoria in pre-pubescent children is based on self-reporting, cannot be thoroughly evaluated, and that only a minority of children who claim to not identify with their biological sex maintain this position after puberty.
January 2023: A study of adolescent patients conducted at Westmead Children's Hospital’s gender clinic found that the evidence-base for the Gender Affirming medical pathway was ‘sparse"‘ and that clinicians feel under pressure to affirm patients:
“For the young people who may regret their choice of pathway at a future point in time, the risks for potential harm are significant."
December 2022: Patrick Parkinson AM told a Queensland Government inquiry that he feared that the practice of gender medicine will emerge as the biggest medical scandal in Australia in 100 years:
“My knowledge of what is going on gives me no reason for confidence that the prescription of powerful and life-altering drugs is occurring only after rigorous assessment or careful evaluation of the reasons why the child or young person may be wanting to embark upon this lifelong medical treatment pathway.”
July 2022: The London Tavistock Clinic announced that it would close after an independent review found "significant gaps in the research and evidence base."
"[In the UK] the clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced."
- The Cass Review, Interim Report
The President of the Australian National Association of Practicing Psychiatrists spoke to Sky News about the UK's more cautious approach.
May 2022: Queensland paediatrician Dr Dylan Wilson publicly urged other doctors not to refer young patients to gender clinics:
"...there exists a service at my local children’s hospital, and at other hospitals around the country, to which I will never refer a child. I believe this service is not appropriate for children, and is actively doing harm...I am talking about the paediatric gender service at my local children’s hospital."
March 2022: The Australian National Association of Practicing Psychiatrist's practitioners guide for Managing Gender Dysphoria/Incongruence in Young People cautioned that treatments with puberty blockers and cross-sex hormones aren’t fully reversible and that there is a lack of consensus that they lead to better outcomes:
"...there is no consensus that medical treatments such as the use of puberty-blocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psycho-social adjustment”
February 2022: The French National Academy of Medicine noted that there was a risk of “over-diagnosis” in gender affirming practice and urged caution in prescribing cross sex hormones and puberty blockers to minors.
February 2022: Sweden's National Board of Health and Welfare found that the risks of hormonal treatments outweigh the benefits for most young people. The Board decided that moving forward, access to hormonal interventions for minors would be tightly restricted and treatment eligibility will be provided on the basis of distress, not ‘identity’.
August 2021: The Royal Australian and New Zealand College of Psychiatrists acknowledged that evidence and professional opinion was divided on whether the gender-affirming model is suitable for children:
"Gender Dysphoria is an emerging field of research and, at present, there is a paucity of evidence."
July 2021: The Society for Evidence based Gender Medicine (SEGM) conducted an independent inspection of the references supporting AusPATH's Public Statement on Gender Affirming Health Care, including for trans youth. SEGM found:
"AusPATH relies on poor quality research, fails to highlight the methodological limitations of most studies and at times misrepresents or exaggerates the research findings and conclusions. AusPATH also mischaracterises psychotherapy for gender dysphoria as potentially harmful. "
March 2021: Clinical psychologist Dr Sandra Pertot questioned Gender Affirming Care on a podcast for the Australian Psychological Society. She told The Age that she had seen a marked uptick in patients presenting with sudden, late-onset dysphoria:
“While some described a long history of distress with their bodies, others had only come to the belief in recent months that they experienced gender dysphoria, after learning about it online. In some cases a parent attended a consultation and said this had taken them by surprise as there had been no indications that their child had any confusion about their gender identity.”
March 2021: The Australian National Health and Medical Research Council told The Australian that the 2018 RCH guidelines were not of a high enough quality to be considered for inclusion in its Australian Clinical Practice Guidelines:
"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
July 2020, a Finnish health advisory body found that in young patients with both gender dysphoria and significant psychiatric comorbidities, “no conclusions can be drawn on the stability of the gender identity of the child." It also said:
"The reliability of the existing studies with no control groups is highly uncertain, and because of this uncertainty, no decisions should be made that can permanently alter a still-maturing minor’s mental and physical development." And, "It is not known how the hormonal suppression of puberty affects young people’s judgement and decision-making." (SEGM Translation).
June 2020: Over 70 medical professionals signed a letter to the Federal Health Minister warning that current treatment practices lacked an evidence base, were experimental, and posed medico-legal risks:
“We believe that major interventions with uncertain harms and damage on the basis of poor evidence and doubtful capacity regarding the provision of informed consent, amounts to medical experimentation”
“We warn that the experimental nature of ’affirmation therapy’ with its withholding of publicised side effects renders Ministers of Health medico-legally vulnerable noting the High Court of Australia’s ruling in Rogers v Whitaker [1992] HCA 58.”
May 2020: The Australian Medical Association Queensland called for practitioners to come together to write new national treatment guidelines in a submission to the Queensland government:
“AMA Queensland would suggest that more research is needed across all the domains of care for children and adolescents who present with gender dysphoria”
January 2020: Dr Cary Breakey Child, Adolescent & Family Psychiatrist submitted to the Queensland Health Legislation Amendment Bill that he held grave concerns for children rushed onto hormonal treatments, and that other diagnoses were being overlooked under the current medical model:
“For almost all of the Gender Identity Disorder/ Gender Dysphoria patients I have seen, there were clear (but different in each) family issues which made choice of the opposite gender an understandable response Problems ranged from relatively uncomplicated sibling “favouritism” to risks of sexual abuse, (real and perceived). In many, there was a strong history of inter-generational sexual abuse, domestic violence, and/or high occurrences of tragedy for either males or females in the family. Dealing with these issues with the patient and family members both resolved the gender issues, and improved family functioning. “
September 2019: Over 200 Australian medical practitioners signed a letter from Professor John Whitehall demanding a Federal Parliamentary Inquiry into child social and medical transitioning.
“It is my view that lack of evidence for effect and denial of side effects renders the Medical Pathway of treatment of childhood gender dysphoria experimental”
November 2019: The Medical Affairs Committee of the Endocrine Society of Australia, (a sub-specialty college of the Royal Australasian College of Physicians) opposed an endorsement of the 2018 RCH Guidelines. In a letter to the RACP, the ESA wrote:
“This is a complex area, the evidence base is limited and the RCH document largely reflects the authors’ opinion because, as the authors themselves state, ‘the published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations’."
- Reported by Natasha Robinson for The Australian
October 2019: The Australian National Association of Practicing Psychiatrists (NAPP) called for a federal parliamentary inquiry into the treatment of child gender dysphoria. A statement from the NAPP identified several areas of concern, including:
"...the child’s capacity for informed consent, and the medical risks, known and unknown, of treatment with puberty blockings drugs, sex hormones and surgery before the age of 18 years."
December 2018: After the publication of the 2018 Royal Children’s Hospital guidelines, a response, published in the medical journal The Lancet argued that:
“The health of transgender children is addressed with imprecise language and overplayed empirical evidence in new Australian guidelines.”