This is an open letter sent to all NSW MP’s on 5th November 2023. The letter was referred to in a recent article in The Australian – Alarm at gender dysphoria treatment (archive link).

5th November 2023 Re: Open letter from clinicians concerned about the NSW Government’s flawed framework for gender treatment services for children and young people. We are writing to you because of our serious professional concerns regarding the NSW Government’s framework for gender treatment services for children and young people. 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. Released in July, 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. We believe that if this framework is adopted uncritically by gender health services, some of the state’s most vulnerable children and young patients could potentially suffer unnecessary and irreversible harms. Titled the Framework for the Specialist Trans and Gender Diverse Health Service for People Under 25 Years, it prioritises the “affirmation model” for medically transitioning children and young people grappling with gender dysphoria, even though this treatment model has been dramatically scaled back in the UK and several European countries. The framework directs state-run “specialist” trans and gender diverse treatment services to follow the intervention recommendations of AusPATH and WPATH, both pro-affirmation organisations whose membership includes activists as well as health professionals. One of the framework’s significant limitations is its failure to provide psychotherapeutic treatment options for children and young people who do not undergo medical transition. This raises concerns about the comprehensiveness and inclusivity of NSW’s model of care. The framework’s foundations were laid out in an “evidence check” rapid review conducted by health NGO the Sax Institute, for the NSW Ministry of Health in September 2020. The Sax Institute’s review supported the use of puberty blockers and cross-sex hormones, considering them effective and safe. (1) However, the UK’s October 2020 National Institute for Health and Care Excellence (NICE) reviews (2, 3) cast doubt on the clinical value of puberty blockers and questioned the safety and effectiveness of gender-affirming hormones. The disparity between the reviews is troubling, and highlights a significant divergence in their conclusions. A critical difference emerges in the approach to the quality of research literature. While the Sax Institute acknowledged the poor quality and high risk of bias in the research studies it relied on, it still included their findings to justify the continued use of puberty blockers and cross-sex hormones for children and young people. This raises fundamental questions about the validity and reliability of the evidence guiding the Sax Institute review of the treatment of gender dysphoria. The Sax Institute review also faces criticism for insufficiently highlighting known concerns and risks associated with puberty blockers and cross-sex hormones. These include impacts on fertility, cognitive development, surgical risks, and long-term physical and psychosocial health implications. Despite this, on 11th July 2023 the NSW Minister for Health, the Hon. Ryan Park MP announced that the Sax Institute had been commissioned to undertake an “evidence check” following the ABC Four Corner’s episode screened the previous evening regarding the provision of gender treatment to children and young people in the state. As the debate around gender treatment continues, it is crucial to navigate the complexities with a thorough understanding of the diverse clinical perspectives and their fundamental implications for the well-being of children and young people. However, given the inadequacies outlined above, we, the undersigned are deeply concerned about the decision to reappoint the Sax Institute. We question the institute’s capacity to provide balanced and comprehensive advice to the NSW Government on this sensitive and complex matter. We also firmly believe that NSW’s gender treatment framework needs to be urgently reconsidered. Signatories to the open letter:

• Dr Alhussain Aldabbagh MBChB FRACP Paediatrician

• Dr Don Bornstein MBBS, DPM, FRANZCP, Cert. Child and Adolescent Psychiatry Child Psychiatrist (retired)

• Dr Cary Breakey MBBS, FRACGP, DPM Child Psychiatrist (retired)

• Dr Robert J. Brennan BSci, BHSc, MBBS Medical Doctor and Psychotherapist

• Dr Rachel Chan BMedSt, MD, FRACGP General Practitioner

• Dr Danielle Collins BMBS, FRACGP General Practitioner

• Dr David Cooke MBBS, FRACGP, FACRRM General Practitioner

• Dr Alida Connell FRANZCP MBChB, DMH, MMed, FCPsych Psychiatrist

• Dr Catherine Crowley MBBS, DipCH HMO Medical Doctor

• Dr Mei Ling Doery MBBS, BMedSci, MPH Medical Doctor

• Dr Andrew Firestone MBBs, DPM, MRCPsych, FRANZCP Psychiatrist

• Dr Randy Juanta BMBS Medical Doctor

• Dr Mary Jessop MBBS, FRANZCP Child Psychiatrist

• Dr George Halasz MBBS, BMedSc, MRCPsych, FRANZCP Child Psychiatrist

• Dr Catherine Hollier MBBS, FRACGP General Practitioner

• Dr Andrew Hughes MBBS, FRACGP, FACRRM, DRANZCOG General Practitioner

• Dr Rosemary Isaacs MBBS, FRANZCP General Practitioner

• Dr Sandy Kershaw MBBS Medical Doctor

• Dr Mary Koshi MBBBS, DGO OBGY (retired)

• Dr Aniello Iannuzzi BA, MBBS, MMedSci, FACRRM, FRACGP, FARGP, FAICD General Practitioner

• Dr Vincent Keane MBBS, DipRACOG, MPH&TM (USA), FAFPHM (RACP) Public Health Medical Doctor

• Prof Dianna Kenny PhD, MA (Sch Couns), BA (Hons), Dip Ed, Grad Dip FDR, FAPs, MAPA Consulting Psychologist, Psychotherapist, Couple and Family Therapist

• Dr Deirdre Little MBBS, DRANZCOG, FACRRM, GCBioeth General Practitioner

• Dr Eamonn Mathieson MBBS, FANZCA Anaesthetist

• Dr Chukwuemeka Okorafo MBBS, FRACGP General Practitioner

• Dr Luke O’Regan B Med FRANZCP Psychiatrist

• A/Prof Peter Parry MBBS, Ph.D, FRANZCP, Cert. Child and Adolescent Psychiatry Child Psychiatrist

• Dr Vivian Praeger FRACGP General Practitioner

• Dr Sarah Price MBBD, FRACNEM, FASLM General Practitioner

• Dr Nic Rosoman MBBS Medical Doctor

• Dr Julie Sladdon MBBS, BMEdSci, PGDipMedEd Medical Doctor

• Dr Mike Sladdon MRCP, RACD, MAE Dermatologist

• Dr Jillian Spencer MBBS, BmedSci, FRANZCP, Cert. Child and Adolescent Psychiatry, Cert. Forensic Psychiatry, Grad Dip For Beh Sci Child Psychiatrist

• Dr Guy van Hazel MBBS, FRACP, FRCP Medical Oncologist

• Dr John Warlow MB, CHB, BIRM, FRANZCP Child Psychiatrist

• Dr Jennifer Wells MBBS, FACD Dermatologist

1. Evidence for effective interventions for children and young people with gender dysphoria | Sax Institute;

2. National Institute of Health and Care Excellence. Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. Oct 2020; and

3. National Institute of Health and Care Excellence. Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria. Oct 2020.