The year started with the Queensland conservative government implementing a pause on puberty blockers and gender affirming care in the public health system for new patients temporarily. The ban did not affect existing patients, but those stuck on the waiting list or those currently being assessed for gender dysphonia. The move put them out of step with the rest of the country and drew criticism from the federal government as well as LGBTQIA+ advocates. The ban did not affect the private health system and therefore meant that families with enough resources could still seek treatment either interstate or through private clinics. In October, the ban was overturned by the Queensland Supreme Court due to insufficient consultation and ideological influence. However, the government reinstated the ban using a ministerial order in less than 24 hours. The independent review lead by Victoria’s former chief psychiatrist Professor Ruth Vine was concluded on the 28th of November with the report release on the 19th of December alongside an announcement by Queensland Health Minister Tim Nicholls that the ‘pause’ would remain in place until 2031 awaiting the outcome of the Pathways trial in the UK. However, it is very clear that the Government’s decision is largely out of step with the information and conclusions reached in the report and therefore shows their actions are driven more by ideology than safety.
There is limited evidence
The review repeatedly highlights the limited evidence for puberty blockers and gender affirming hormone treatment in trans youth, sighting limitations in the types of studies including sample size, short-term studies, and methodologies. This is not surprising to anyone as it has long been documented by previous reviews, including the Sax Institute Update last year, that there is a lack of evidence. This is due to a few factors, including the fact that paediatric medicine in general has limited studies and trials due to the ethical issues of running such research with young people. However, beyond this, it has been well documented that transgender health care has been largely ignored, and therefore, exports and governments have not dedicated resources to investigating the treatment of gender dysphoria. after all, it only relates to approximately 1% of the population. This is why trans advocates have long been asking for better research into treatment. Additionally, it is well known that paediatric medicine often relies on evidence relating to adult treatment (a fact noted in the review) which isn’t possible in reviewing the safety or effectiveness of puberty blockers in the short or medium term. Therefore, as the report states ad nauseam their is limited evidence, and some is inconsistent due to different methodologies as well as selection bias in the small sample sizes. Despite this, the report reaches several conclusions regarding care that should have informed the government.
Benefits and risks
Despite the limitations of evidence, the review makes some clear conclusions based on other reviews conducted and the Joanna Brigs Institute literary review they commissioned. This included “that the systematic reviews which considered the evidence on the impact of PB on psychosocial outcomes indicated improvements in depressive symptoms, anxiety, suicidality, and quality of life.” The extent of these benefits seem to be varied as other factors impact mental health but Professor Vine and her team clearly concluded that based on the available limited evidence there is a clear indication of positive benefits on elevating distress and improve mental health in those being treated for gender dysphoria.
Meanwhile, they also found that the evidence of side effect and risks was limited and inconsistent, the one firm conclusion they could make was the puberty blockers impacted bone density and was not recommended for long term use. They also noted that “where individuals go on to receive GAHT after PB, there is some evidence that BMD recovers to pre-treatment levels.” The impact on fertility was also unsurprisingly the main other risk found based on the available evidence as puberty blockers act at Tanner stage 2 and prevent normal development of the gonads. Rather than suggesting this impact on fertility was enough to ban the use of blockers the report concludes that “consultation and consideration of the options for fertility preservation is an important component of the consent process” and also noted that while the majority of TGD adolescents reported a future with children a large majority were interested in adoption rather than having biological children. In addition, the report also found that for those who desist with treatment, the impact of puberty blockers on fertility is reversible. As such, the review concludes based on the available but limited evidence the following:
“Having considered the JBI literature review, previous reviews and studies and available guidelines, we have concluded that, with proper oversight and appropriate reporting, there can be benefit for a young person in being able to access PB (puberty Blockers). We support treatment only being considered after assessment by a MDT (multidisciplinary team) with experience and expertise in this area and only after any other causes or contributors to the young person’s distress have been considered and resolved to the extent possible.”
But what about regret
The report also goes on to consider the other major scare tactic of anti trans campaigns that suggest allowing gender affirming care for trans youth to create a wave of people detransitioning and young people plagued by regret. This has long been disproven as a fallacy but if we need yet more evidence the report concludes that despite the presence of “multiple reasons why a person desists from or regrets a medical pathway, overall, the regret/desistence rates associated with the use of PB and GAHT in young people appear very low.” This is especially important when considering a potential model of care as if all the information provided to families and proper steps are take there is no evidence to suggest that trans youth are not satisfied with their decisions as they move into adulthood.
Options available to the Goverment
The final part of the report is focused on outlining a series of options for the Queensland government and highlighting the possible avenues for improved oversight.
- Option 1 – “not permit PB or GAHT to be prescribed in Queensland public hospitals”
- Option 2 – “return to the way PB and GAHT were prescribed prior to the 2025 HSD and Ministerial Direction”
- Option 3 – “permit the prescription of PB and GAHT in Queensland public hospitals, but only in accordance with some additional measures introduced by QH as oversight or governance mechanisms to safeguard the safety of use of the treatments”
After outlining these possible options that report unpacks the potential problems associated with Option 1 and 2. Noting specifically that “Option 1 has inherent risks and has limited efficacy in ensuring equitable and accessible PB and GAHT to those who need it and meet specified qualifying criteria in the safest manner and in their best interests.” This criticism clearly articulates the denial of care as problematic for those that meet the criteria which reinforces the earlier conclusion of the review that supported treatment based on a proper MDT assessment. In addition the review also raises concerns around the inequality created by denying public health services while treatment is available through private clinics or interstate and therefore unfairly impacts trans youth from low social economic families. In contrast the concerns surrounding option 2 are focused on the extent of reforms to the QCGS as to whether it suitably address risks within the system and seems to be more positively viewed by the panel.
The clear path forward that is really advocated in the report is option 3 to permit PB and GAHT with additional measures and improved oversight. The review concludes that the “provision of PB and GAHT in the public hospital system is therefore more likely to enable the medications to be accessed by those who need it in the most safe, comprehensive and effective environment and with system supports, such as embedded capacity for legal and ethical consultation, to enable and promote continuing improvement of the service.” In fact, the final chapter of the report is directed to expanding on the possible measures that could be implemented by Queensland and in cooperation with state and federal services. The report also notes that implementing option 3 would also allow for better data collection and help address the limitations in the available evidence.
Clearly the government ignored this review
After reading the report, it is pretty clear that the actions of the Queensland government are not actually in line with the conclusions reached by Professor Vine and her panel. It concludes that PB and GAHT have a positive benefit on mental health and clearly supports access to treatment for those who need it with the appropriate oversight. Instead of enacting the reforms and models suggested in the report to make treatment safer, the government has decided to follow the one option that is heavily criticised due to risks and limited efficiency. They seem to focus on the limited evidence and the reversible impact on bone density for justification for continuing their ban.
This decision in light of the Vine review clearly highlights that the government is not acting on the evidence provided or the advice of experts but rather looking to push an agenda based on anti-trans ideology. After all, this is a government that, in opposition, spoke against reforms to allow for self identification for trans people and whose members echo gender critical talking points. They willingly allow their beliefs to impact the lives of vulnerable young people rather than allowing for equitable access to medical care. That governments will act against public interests in this way is disgusting.
My hope is that their actions will once again be challenged in court and that it will be stuck down as not in the public interest. In the mean time my thoughts are with families and trans youth in Queensland faced with this ongoing battle and the denial of medical care.
