Anti-trans groups such as the Australian Christian Lobby (ACL) and other conservative voices, including some MPs and healthcare professionals, are spreading disinformation and anti-trans rhetoric, including calling for the withholding of gender-affirming care of young folk.
These groups are often known for fearmongering via the media and other means – for instance they have been using a problematic clinical review of gender-affirming care conducted in the UK to call for changes to be implemented in Australia.
As nurses and midwives, we are proud to practice in a way that is person-centred, evidence based and consistent with the Nursing and Midwifery Board of Australia standards and codes. As such, sometimes we must scratch the surface to ascertain whether cited evidence is all it appears to be. Gender-affirming care is one such area where the growing body of evidence supporting best-practice person-centred care is being challenged.
The Cass Review
In 2020, NHS England commissioned an independent review – led by paediatrician Dr Hilary Cass – of gender identity services for children and young folk in the UK. The review was commissioned following concern regarding the blow out in waiting list times at the Tavistock Gender Identity Development Service, the only such service in Britain. The four-year review has recently released its final report.
There have been significant concerns regarding this review, which will have world-wide implications. Two key issues are summarised below.
Evidence selection
The Cass Review only included studies that were based on randomised control trials. Whilst these are normally considered the ‘gold standard’, they are not always appropriate. This is particularly relevant when the drugs involved have a clear and noticeable effect. For this study, the drugs in question were puberty blockers (medications that delay the onset of puberty).
Much of the evidence supporting gender-affirming healthcare is based on a significant body of observational studies, and according to Dr Portia Predny (Vice President of The Australian Professional Association for Transgender Health) ‘when you have multiple observational studies looking at a particular intervention and those studies are producing similar findings, the cumulative evidence becomes compelling.’ (Equality Australia 2024).
However, despite this body of evidence forming the basis of transgender healthcare around the world, the Cass Review chose to exclude 100 studies out of 102 that it considered.
Failure to include lived experience and/or relevant expertise
The Assurance Group and other consulting structures associated with the Cass Review did not include any trans folk, nor were clinicians with experience in the field included.
Instead, for the interim report, they chose to consult people who were known to be sceptical of the use of puberty blockers, others who believe trans folk are mentally ill, and those that support conversion practices (which is being progressively outlawed here in Australia) (Trans Justice Project 2024).
Why this matters and Australian responses
Unlike the UK, Australia has a robust system in place for providing multi-disciplinary gender-affirming care to adults and young folk that is among the best in the world. There are a number of gender clinics around the country, including state-funded services specialising in the care of children and adolescents (Lane, 2024). Their professional practice and delivery of care is in line with the World Professional Association for Transgender Health (WPATH) Standards of Care, whose guidelines are regularly updated in relation to appropriate and valid emerging evidence from around the world (Coleman et al 2022).
Following the release of the Cass Review, Victorian Health Minister Mary-Anne Thomas stated that ‘our gender clinics offer some of the most vulnerable young people in our community the support they deserve – we’re fiercely proud of the work they do.’ (Davey 2024). These sentiments have been echoed by other health ministers around the country. (Davey 2024).
Experienced healthcare professionals who are experts in Australian transgender health have expressed concern with the Cass review. Associate Professor Ada Cheung, head of the Trans Health Research Group at the University of Melbourne highlighted that ‘the Cass report goes against the consensus of professional medical associations around the world and I don’t think is relevant to practice in Australia.’ (Davey 2024).
An Australian national online survey, Trans Pathways (Strauss 2017), looked at the experiences of transgender youth. This showed that 72% have been diagnosed with anxiety, 75% with depression, 80% have self-harmed and 48% have attempted suicide. These figures do not indicate a group of people who are inherently unwell as some would like us to believe. These figures illustrate the impacts of stigma and discrimination.
The benefits of gender-affirming, person-centred care have been well documented. Jeremy Wiggins, CEO of Transcend Australia, states that ‘families with trans children deserve timely access to gender-affirming healthcare. It’s a major protective factor and safeguard against poor mental health and suicidality.’ (Equality Australia 2024). The Australian Medical Association has also called for improved access to gender-affirming care as it recognises that this care provides a range of positive health outcomes. (AMA 2023).
Transcend Australia (a registered, community-led organisation providing support for trans and gender diverse young folk and their families and carers) commented, ‘while we acknowledge the value of international efforts to continue to develop our knowledge and understanding about this critical area of care, we can only rely on robust, ethical and methodologically sound research practices and reviews. The Cass Review is not an example of this.’ (Transcend Australia 2024).
Nurses and midwives have a profound impact on the lives of those they care for. To provide affirming care to trans youth and their families no matter what the clinical interaction, we need to be aware of the larger body of evidence that informs this care and avoid falling into the trap of disinformation and misinformation that is being perpetuated by groups with an anti-trans agenda. It is not just young people who are impacted by this public ‘debate’. Trans and gender diverse people of all ages are entitled to inclusive, affirming care no matter where or how they are interacting with the health system.
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I would like to acknowledge the invaluable assistance from Rebecca Clark and Meredith Butler in the writing of this article.
Co-convenor ANMF LGBTIQA+ Reference Group (lgbtqia.referencegroup@gmail.com)
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References
Australian Medical Association (2023) LGBTQIASB+ Health Position Statement ama.com.au/articles/lgbtqiasb-health-position-statement
Cass, H (2024) The Cass Review – Independent review of gender identity services for children and young people cass.independent-review.uk/home/publications/final-report/
Cohen, J (2021) Michelle Telfer has been a lifesaving advocate for hundreds of trans children. But her work doesn’t come without controversy. abc.net.au/news/2021-05-24/michelle-telfer-trans-children-health/100137192
Coleman, E et al (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 in International Journal of Transgender Health, 23:sup1, S1-S259
Davey, M (2024) ‘What implications does England’s review of trans healthcare have for Australia?’ in The Guardian 20 April 2024 theguardian.com/australia-news/2024/apr/20/england-nhs-dr-hilary-cass-review-transgender-healthcare-impact-australia
Equality Australia (2024) Cass Review out-of-line with medical consensus and lacks relevance in Australian context equalityaustralia.org.au/cass-review-out-of-line-with-medical-consensus-and-lacks-relevance-in-australian-context/
Lane, R (2024) ‘Cass final report: a major setback’ in Workers’ Liberty 17 April 2024 workersliberty.org/story/2024-04-17/cass-final-report-major-setback
NMBA (Nursing and Midwifery Board of Australia) (2018) Code of Conduct for Nurses nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
NMBA (Nursing and Midwifery Board of Australia) (2018) Code of Conduct for Midwives nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Pang K, Wiggins J and Telfer M (2022) ‘Gender identity services for children and young people in England’ in BMJ 2022;377:o825 dx.doi.org/10.1136/bmj.o825
Strauss P, Cook A, Winter S, Watson V, Wright Toussaint D and Lin A. (2017). Trans Pathways: the mental health experiences and care pathways of trans young people. Summary of results. Telethon Kids Institute, Perth, Australia.
Telfer M, Tollit M, Pace C and Pang K (2020) Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.3 Melbourne The Royal Children’s Hospital
Timms, P (2024) ‘The Cass Review into medical care provided to children with gender dysphoria has been released. Here’s what it found. In abc news 15 April 2024 abc.net.au/news/2024-04-12/gender-dysphoria-cass-review-medical-treatment-children/103700476
TransActual (2024) Press release: The Cass Review is bad science and should not be taken seriously by policymakers transactual.org.uk/blog/2024/04/11/press-release-the-cass-review-is-bad-science-and-should-not-be-taken-seriously-by-policymakers/
TransActual (2024) The Cass Report – A Briefing transactual.org.uk/wp-content/uploads/TransActual-Briefing-on-Cass-Review.pdf
Transcend Australia (2024) The Cass Review transcend.org.au/blog/the-cass-review/
Trans Justice Project (2024) Cass Review Fact Sheet transjustice.org.au/resources/
