In 2020, the NSW government commissioned the Sax Institute to conduct a review of “Evidence for effective interventions for children and young people with gender dysphoria”. This report was used to support its “Framework for the Specialist Trans and Gender Diverse Health Service for People Under 25 Years”, which was unveiled last year.
Since 2020, however, growing concern from local clinicians, supported by evidence emerging internationally, has brought the direction of this policy into question. From 2021, clinicians at Sydney’s Westmead Children’s Hospital raised concerns about the growing number of children presenting with gender dysphoria and the expectations that they would be fast-tracked to medical interventions. These clinicians recommended a biopsychosocial, trauma-informed approach that addresses “unresolved trauma and loss, the maintenance of subjective well-being, and the development of the self” instead.[1] Media attention on this issue[2] and questions raised in the NSW Parliament by Greg Donnelly MLA[3], created pressure for NSW Health to justify its ongoing support for medical sex trait modification. In response, NSW Health commissioned an “update” to its initial evidence review. This was released last week, together with an info-graphic-style summary of the high level conclusions.
Unfortunately, for all the words generated, this exercise is unlikely to silence the growing disquiet about medical gender affirmation for children in Australia. What is needed is a genuinely independent, wide-ranging and transparent review of the type lately conducted in the UK by Dr Hilary Cass. For reasons explained here, the Sax Institute report is no substitute.
Not independent
First, the Sax Institute is not independent of NSW Health.
NSW Health has committed heavily to the medical model, both through its support for the Maple Leaf House gender clinic, affiliated with John Hunter Hospital in Newcastle, and through the millions of dollars – nearly $14 million for the financial year 2022/2023[4] - it provides to the AIDS Council of NSW (ACON), which operates as an activist lobby group promoting medical gender affirmation.
NSW Health also funds the Sax Institute. Under the heading “Economic Dependency”, the Sax Institute’s 2022/23 Annual Report notes that:
“The Sax Institute is dependent on the NSW Ministry of Health (the 'Ministry') for a significant contribution to fund corporate costs. The Ministry provides funding on a quarterly basis. It is anticipated that adequate funding will be provided to enable the Institute to pay its debts as and when they fall due. Funding agreements are entered into for five year periods with the current agreement in effect from 1 July 2018 to 30 June 2023. The Ministry has formally agreed to extend this funding agreement to 30 June 2028.”[5]
The Sax Institute received nearly $6 million in government grants for the financial year 2022/23.[6] Under these circumstances, it seems unlikely that it would deliver findings contrary to the interests of its client.
The work of the Sax Institute is supported by “a network of experts nationwide to analyse policy problems and find the best evidence-based solutions”.[7] While this is not problematic in itself, the Sax Institute’s member list features many organisations with commitments to medical gender affirmation. The extent to which these might have influenced the Sax Institute’s findings is opaque but the association might be seen by some to justify a degree scepticism about the Sax Institute’s impartiality on the issues under investigation.
For reasons that are not explained, the 2024 “update” appears to have been outsourced by the Sax Institute to a research groups called “Behaviour Works” at Monash University, which boasts of being “the largest university-based applied behaviour change research unit in Australia”.[8] Behaviour Works’s website assures readers that “We do research for good … Our behaviour change programs are for the good of the planet and its people.”[9] The clear problem here is that those who are already concerned about the potential for evidence to be manipulated with propagandistic effect are unlikely to be reassured that an organisation averring that “Persuading people is both an art and a science” and “Our research is your evidence”[10] is also committed to delivering a reliable, impartial representation of the facts.
Further, the Sax Institute report repeats uncritically the “minority stress” or “stigma” theory favoured by advocates of medical sex trait modification as justification for fast-tracking “affirmation” and eschewing exploratory psychotherapy. Readers are told, as though it were the whole truth, that:
“Children and young people who are trans and gender diverse (TGD) or have gender dysphoria are a vulnerable population as a result of stigma and marginalisation. Because of this and minority stress, they experience high rates of mental health and behavioural problems as well as social, educational and economic disadvantage”.[11]
The impression of bias is fortified by the fact that the Sax Institute’s conclusions have not been confined to an objective assessment of peer-reviewed literature (quite a lot of which, in any case, is acknowledged to be low-quality)[12]. Its 2020 report acknowledged that it relied on “expert consensus” to fill in gaps where evidence is lacking:
“Because of the low number and quality of included studies for each question, we considered it important to include guidelines and position statements from experts in this area. Additionally, to inform practice in emerging fields of research such as TGD adolescent health, it was necessary to include expert consensus in the form of expert opinions, committee statements and clinical guidelines where quality of evidence is lacking.”[13]
The University of York researchers commissioned by the Cass Review to evaluate international guidelines have pointed to the problem of “circularity” in the mutual citation of different guidelines which, they say, “may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”[14] Consensus that arises under such circumstances cannot substitute for actual evidence. It is entirely possible that foundational errors are simply being reproduced and amplified within an ideologically aligned community of “experts”.
Asking the wrong questions
Every good academic knows that the key to illuminating a field of inquiry is asking the right question. Unfortunately, every propagandist and every canny politician knows this too. A cleverly-crafted question can obscure as much as it illuminates and produce false or only-partially-correct conclusions that might look superficially reliable.
The Sax Institute was asked to provide answers to the following questions:
- Question 1: What are effective clinical medical interventions for TGD children and young people and those with gender dysphoria?
- Question 2: What are the effective psychosocial interventions for TGD children and young people and those with gender dysphoria?
Subsidiary questions allowed for the consideration of risks associated with either treatment approach.
These questions include a number of implicit assumptions and ambiguities which - if we assume the goal of the report is to provide clarity as to the best treatment model for children - are problematic.
First, the questions presuppose there is a category of children that can confidently be labelled “TGD” (“trans or gender diverse”); by implication, TGD children can be distinguished from “not TGD” children. In fact, both suppositions are worthy of investigation. Questions about the diagnostic process – or even the nature of what is being diagnosed – bedevil contemporary debate. The Cass Review commented that the criteria established in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5), commonly used to establish a diagnosis of “gender dysphoria”, may help in establishing a young person’s distress but “do not help in determining which factors may have led to this distress and how they might best be resolved … a broader psychosocial assessment should be conducted and evaluated, and what other factors need to be considered to gain a holistic understanding of the child or young person’s experience.”[15]
A second, related, question is whether “TGD children” (however this group is to be defined) and “those with gender dysphoria” are the same group, distinct groups or overlapping groups of children and young people. As stated in the Cass Review’s Final report: “The widely understood challenge is in determining when a point of certainty about gender identity is reached in an adolescent who is in a state of developmental maturation, identity development and flux.”[16] The Sax Institute was not required and did not attempt to address this issue.
How the patient cohort is defined has implications for the further questions about what is being treated and how we evaluate “success”. If “gender dysphoria” is the problem identified for treatment then, presumably, an intervention that reduces dysphoria will be regarded as “effective”. But is simply “reducing dysphoria”, without engaging with the aetiology and possible reasons for the dysphoria, the correct clinical objective? Advocates for “gender affirmation” would say “yes”; critics of “gender affirmation” would say “no”.
The biased and limited terms of reference provided to the Sax Institute appear to particular disadvantage when contrasted with the broad and wide-ranging scope provided to the UK’s Cass Review. Cass was tasked with making “recommendations on how to improve services for children and young people experiencing issues with their gender identity or gender incongruence, and ensure that the best model/s for safe and effective services are commissioned.”[17] Of note, these terms of reference do not foreclose on the status – TDG or otherwise – of the patient cohort and this is relevant when we then come to consider treatment options.
The Sax Institute’s search terms produced only three studies relating to psychotherapeutic interventions and none that “examined the outcomes of supportive psychological therapies, either neutrally or affirmatively framed.[18] The Cass Review encountered a similar paucity of studies specifically relating the treatment of gender dysphoria but, because it was not constrained to consider only “TGD” children, Cass was able to apply common sense to the problem:
“We know that many psychological therapies have a good evidence base for the treatment in the general population of conditions that are common in this group, such as depression and anxiety. This is why it is so important to understand the full range of needs and ensure that these young people have access to the same helpful evidence-based interventions as others.
… the focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective”.[19]
Assertion that puberty blockers are ‘safe, effective and reversible’ contradicts international evidence
Given the difference in the terms of reference, it is perhaps not surprising the Sax Institute and the Cass Review came be very different conclusions on a number of important questions. To take just one example, on the subject of puberty blockers, the Sax Institute concluded that “newly identified evidence reinforced the finding of the previous Evidence Check regarding benefits and effectiveness. That is, PS [puberty suppression] agents (generally referred to as GnRHa) were reported to be safe, effective and reversible.”[20] Consistent with its established record of cheerleading for the medical affirmation model, the ABC amplified this conclusion in a headline which declared: “Puberty blockers a 'safe, effective and reversible' form of gender-affirming care, finds review triggered by Westmead Hospital investigation”.[21]
For those familiar with this contentious subject, this may seem like the most preposterous assertion of all to come from the Sax Institute report. At one time, the claim that puberty blockers are fully reversible featured on the NHS’s website. It was quietly removed in 2020, amid evidence to the contrary presented to the UK Divisional Court in the proceedings of the Bell v Tavistock case.[22] The court rejected the Tavistock’s claim that puberty blockers merely give the child “time to think” about whether or not to proceed to cross-sex hormones. It said:
“the use of puberty blockers is not itself a neutral process by which time stands still for the child on PBs, whether physically or psychologically. PBs prevent the child going through puberty in the normal biological process. As a minimum it seems to us that this means that the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity. There is an argument that for some children at least, this may confirm the child’s chosen gender identity at the time they begin the use of puberty blockers and to that extent, confirm their GD [gender dysphoria] and increase the likelihood of some children moving on to cross-sex hormones. Indeed, the statistical correlation between the use of puberty blockers and cross-sex hormones supports the case that it is appropriate to view PBs as a stepping stone to cross-sex hormones.
138. It follows that to achieve Gillick competence the child or young person would have to understand not simply the implications of taking PBs but those of progressing to cross-sex hormones. The relevant information therefore that a child would have to understand, retain and weigh up in order to have the requisite competence in relation to PBs, would be as follows: (i) the immediate consequences of the treatment in physical and psychological terms; (ii) the fact that the vast majority of patients taking PBs go on to CSH and therefore that s/he is on a pathway to much greater medical interventions; (iii) the relationship between taking CSH and subsequent surgery, with the implications of such surgery; (iv) the fact that CSH may well lead to a loss of fertility; (v) the impact of CSH on sexual function; (vi) the impact that taking this step on this treatment pathway may have on future and life-long relationships; (vii) the unknown physical consequences of taking PBs; and (viii) the fact that the evidence base for this treatment is as yet highly uncertain.
139. It will obviously be difficult for a child under 16 to understand and weigh up such information.”[23]
The Cass Review found “no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes, which without a control group could be due to placebo effect or concomitant psychological support...
“It is known that adolescence is a period of significant changes in brain structure, function and connectivity. During this period, the brain strengthens some connections (myelination) and cuts back on others (synaptic pruning). There is maturation and development of frontal lobe functions which control decision making, emotional regulation, judgement and planning ability. Animal research suggests that this development is partially driven by the pubertal sex hormones, but it is unclear whether the same is true in humans. If pubertal sex hormones are essential to these brain maturation processes, this raises a secondary question of whether there is a critical time window for the processes to take place, or whether catch up is possible when oestrogen or testosterone is introduced later.”[24]
“An international interdisciplinary panel has highlighted the importance of understanding the neurodevelopmental outcomes of pubertal suppression and defined an appropriate approach for investigating this further.”[25]
In short, puberty blockers interfere with brain maturation and development, and it is not clear whether these changes can be deferred without consequence. There is now such strong international evidence to contradict the assertion of the Sax Institute that this issue alone will be seen as justification for disregarding any of its other assertions.
Those who identify the strong professional consensus among a small group of highly-networked, ideologically aligned individuals and organisations with a common professional, reputational and/or financial interest in the medical model as the problem, are likely to see the Sax Institute report as just another data point proving their case. Australians who are aware of the sophisticated academic discourse concerning the many complex issues raised by medical sex trait modification for children, are justified in expecting a better answer than this from the NSW government.
[1] Kasia Kozlowska, et al, “Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service”, Human Systems: Therapy, Culture and Attachments, 2021, 1(1), 70–95; Joseph Elkadi, Catherine Chudleigh, Ann M. Maguire, Geoffrey R. Ambler, Stephen Scher, and Kasia Kozlowska, "Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study" Children, vol. 10(2), 2023, 314.
[2] The ABC, which has consistently championed the cause of medical sex trait modification, aired a 4 Corners episode entitled “Blocked: the battle over youth gender care” in July 2023. In September, Channel 7 responded with an episode of Spotlight which focussed on “Breaking the Silence: the reality of Detransitioning”.
[3] Greg Donnelly (Chair), Legislative Council Portfolio Committee No. 2 – Health, Hansard, Parliament of NSW, 7 September 2022, 54ff.
[4] Annual Report 2022-2023, ACON, 2023, 88.
[5] Annual Financial Report, The Sax Institute, 30 June 2023, 20.
[6] Op. cit., 15.
[7] “About Us”, Sax Institute [website]. Accessed 9/09/24; “Our members”, Sax Institute [website]. Accessed 9/09/24.
[8] “About”, Behaviour Works [website]. Accessed 9/09/24.
[9] “Home”, Behaviour Works [website]. Accessed 9/09/24.
[10] “About”, Behaviour Works [website]. Accessed 9/09/24.
[11] “Evidence for effective interventions for children and young people with gender dysphoria”, Sax Institute, September 2020, 11. (Hereafter, “Evidence Check: Part 1”).
[12] Evidence Check: Part 1, 5; Evidence for effective interventions for children and young people with gender dysphoria—update, Sax Institute, February 2024, 9.
[13] Evidence Check: Part 1, 5.
[14] Cass Review, Independent review of gender identity services for children and young people: Final report, April 2024, [9.19-9.22], 130. (Hereafter, “Cass Review, Final Report”).
[15] Cass Review, Interim Report, [5.15, 5.17], 60.
[16] Email re: “Independent Review of Gender Identity Services for Children and Young People Further Advice”, from Hillary Cass to John Stewart, National Director, Specialised Commissioning, NHS England, 19 July 2022, reproduced in Appendix 6, Cass Review, Final Report, 2024.
[17] Cass Review, Independent review of gender identity services for children and young people: Interim report, Appendix 1, 87. (Hereafter, “Cass Review, Interim Report”).
[18] Part 1, 12 and 14.
[19] Cass Review, Final Report, [67-70], 30-31.
[20] Evidence Check: Part 2, 10.
[21] Patricia Karvelas, “Puberty blockers a 'safe, effective and reversible' form of gender-affirming care, finds review triggered by Westmead Hospital investigation”, ABC News, Friday 6 September 2024.
[22] “Are puberty blockers reversible? The NHS no longer says so," Transgender Trend [blog], 30 June 2020.
[23] R (on the application of) Quincy Bell and A -v- Tavistock and Portman NHS Trust and others, [2020] EWHC 3274 (Admin), in the UK’s High Court of Justice, Administrative Court, Divisional Court, 1 December 2020, [137]-[139].
[24] Cass Review, Interim Report, [3:32], 38.
[25] Cass Review, Interim Report, [3:33], 39.
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