AusPATH: Activism influencing health policy

Introduction

AusPATH (Australian Professional Association for Trans Health) describes itself as: ‘Australia’s peak body for professionals involved in the health, rights and well-being of all trans people – binary and non-binary’. Its stated aims include: providing education to health professionals; developing best practices and supportive policies; sharing information and promoting communication and collaboration amongst health professionals; encouraging, promoting and disseminating relevant research; and maintaining a network of ‘informed’ professional service providers. ¹ AusPATH functions as a registered charity with the listed purposes of: advancing education, benefiting the community, and acting as an institution whose principal activity is to promote the prevention or the control of diseases in human beings (a health promotion charity). ² Charitable organisations can be registered as public companies limited by guarantee, meaning the liability of the company’s members is limited.

According to the AusPATH commissioned 2022 document ‘A History of Trans Health Care in Australia’, ³ AusPATH was initially established in 2009 by Australian health professionals in partnership with colleagues from New Zealand during a WPATH conference in Norway. The organisation separated along country lines in 2019.

The fledging organisation recruited a membership base of health practitioners. Initially, members had to be registered with a relevant professional regulatory authority. However, these requirements were criticised as ‘gate keeping’, and pressure was exerted to accept trans people without health qualifications as members. AusPATH’s constitution was subsequently changed to admit transpeople and non-registered professionals as full members. Within the organisation, trans members have implored AusPATH to see members with lived experience as experts, and for health professionals to acknowledge their position of ‘privilege’. AusPATH includes non-medical members in its leadership team and within policy, research and education subcommittees. The majority of the current AusPATH board of directors are now trans or gender diverse.

AusPATH’s inclusion of members with lived experience aligns with RANZCP Position Statement 62: ‘Partnering with people with lived experience’, which states: ‘Engagement with people who have lived experience in all aspects of mental healthcare has had transformative effects on service delivery and models of care’. The Statement encourages a partnership model and commits to: ‘Supporting and promoting the role of people with lived experience in advocating for improvements in policy and health services’. Unfortunately, the Statement does not include guidance regarding how to: recruit and integrate voices of people with conflicting lived experience; the impact of lived experience on conscious and unconscious processes of communication with professionals and patients; or the complexity of balancing clinical and research knowledge that conflicts with lived experience accounts.

AusPATH is networked with a range of research institutions, gender clinics and government-funded health organisations, as well as transgender rights organisations. ³ It is an influential proponent of the gender affirming model of care used in all paediatric gender clinics in Australia. This model is underpinned by the AusPATH-endorsed Australian Standards of Care and Treatment Guidelines (ASOCTG). ⁴ These guidelines were recently appraised by the University of York as part of the Cass Review and given failing grades on Rigour of Development (19/100), Clarity of Presentation (41/100), Applicability (19/100), and Editorial Independence (14/100). ⁵

Position statements

AusPATH retains its released position statements on its website dating back to 2019. Within these, the organisation appears to repeatedly provide inaccurate information. Specifically, inter alia: the safety, evidence underpinning, benefits, and role of puberty blockers; low regret rates following adolescent transition; social transition showing evidence of psychological benefit, and psychology being harmful if offered as an alternative to gender affirming interventions.

As ‘experts’ in the field of gender medicine responsible for influencing national health policy, AusPATH was likely to have been, or ought to have been, cognisant of existing information easily available in both academic and public domains indicating such information to be inaccurate. It is beyond the reference limit of this article to dissect all the claims made by AusPATH in its position statements. However, to stimulate discussion, we focus here on statements made by AusPATH in relation to puberty blockers. We refer the reader to the Cass Review Final Report for a summary of the evidence in relation to the other claims raised above (see Table 1).

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Table 1.

Comparison of AusPATH statements with conclusions of the Cass Review Final Report

AusPATH statement	Cass review statement
‘Puberty suppressing hormone treatments have been in use for decades in a variety of clinical contexts, including in the treatment of precocious puberty in young children. They are widely considered to be safe, and their effects reversible’. 6	‘The situation for the use of puberty blockers in gender dysphoria is different. Although some endocrinologists have suggested that it is possible to extrapolate or generalise safety information from the use of puberty blockers in young children with precocious puberty to use in gender dysphoria, there are problems in this argument. In the former case, puberty blockers are blocking hormones that are abnormally high for, say, a 7-year-old, whereas in the latter they are blocking the normal rise in hormones that should be occurring into teenage years, and which is essential for psychosexual and other developmental processes’ (page 174)
‘It is our position that the current evidence base supports PSH as a safe, effective, and beneficial treatment option for many young gender diverse people’. 6	‘The University of York concluded that there is insufficient and/or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health’. (Page 176)
‘In some cases puberty suppressing treatments can be quite literally lifesaving: Buying kids and their families extra time to make really important decisions, with the support of their doctors and health care team’. 6	‘In summary, the evidence does not adequately support the claim that gender affirming treatment reduces suicide risk’. (Page 187)
‘One of the primary goals of puberty suppression is to allow the young person time to decide whether they wish to begin gender affirming hormones. Puberty suppression is completely reversible and therefore this is not an adverse outcome’. 28	‘These data suggest that puberty blockers are not buying time to think, given that the vast. Majority of those who start puberty suppression continue to masculinising/feminising hormones. Particularly if they start earlier in puberty. It was on the basis of this finding that the High Court in Bell vs Tavistock suggested that children/young people would need to understand the consequences of a full transition pathway in order to consent to treatment with puberty blockers ([2020] EWHC 3274 (Admin))’. (page 176)
‘AusPATH states that when gender affirming medical treatment is provided with a standardised multidisciplinary assessment and treatment process, thorough informed consent, and ongoing monitoring and psychosocial support, the rate of regret of gender-affirming medical treatment commenced in adolescence has been observed to be very low and the benefits of treatment in adolescence are potentially greater than the benefits of gender-affirming treatment commenced in adulthood’.	‘The percentage of people treated with hormones who subsequently detransition. Remains unknown due to the lack of long-term. Follow-up studies, although there is suggestion That numbers are increasing’. (Page 33)
‘This is despite recent evidence pointing to positive mental health and social well-being outcomes in children who are allowed to socially transition in supportive environments before puberty’. 31'	‘The information above demonstrates that there is no clear evidence that social. Transition in childhood has positive or negative. Mental health outcomes. There is relatively weak evidence for any effect in adolescence. However, sex of rearing seems to have some influence on eventual gender outcome, and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence. For this reason, a more cautious approach needs to be taken for children than for adolescents’. (Page 164)

Invalid comparison to precocious puberty

In a 2024 statement, ⁶ AusPATH compared the use of GnRH agonists (‘puberty blockers’) for precocious puberty to their use in gender dysphoria. This is misleading for two reasons. Firstly, the two conditions are distinct: in precocious puberty abnormally high hormone levels are being temporarily supressed. In gender dysphoria, puberty blockers are suppressing ‘the normal rise in hormones that should be occurring into teenage years, and which is essential for psychosexual and other developmental processes.’ ⁵ Secondly, the comparison ignores concerns about potential adverse health impacts of using puberty blockers in relation to precocious puberty, including: polycystic ovarian disease, ⁷ reduced bone density ⁸ and IQ reductions in the order of 7–8 points. ⁹ Reviews of the literature on puberty blocker use in precocious puberty acknowledge that further research is required and that there are unresolved questions about the long-term impacts of puberty blockers.^10,11

Describing puberty blockers as safe

In 2020 and 2024 statements,^6,12 AusPATH labelled puberty blockers as ‘safe’ without clarifying the meaning of this term, but it infers that children prescribed them will not be harmed. Such unqualified statements, made by professional organisations seeking to influence health policy, are unusual.

Safety concerns about puberty blockers are longstanding. As early as 2006, the need for research into the impact of puberty blockers on the developing adolescent brain was recognised. ¹³ In 2015, the Dutch published a small study finding adolescent males undergoing puberty suppression had reduced accuracy scores on a test of executive functioning. ¹⁴ In 2017, randomised control trials on sheep indicated that puberty blockers permanently impair spatial memory. ¹⁵ Such recognized risks led to the Finnish Council for Choices in Health Care 2020 guidelines to raise the concern that puberty blockers may negatively impact brain maturity. ¹⁶

Concerns about the impact of puberty blockers on bone density were raised as early as 1996, ¹⁷ and the detrimental effect of puberty blockers on the accrual of normal bone mass has been documented in longitudinal studies.^18,19

Infertility or sterility and lack of sexual function does not appear salient for AusPATH when declaring puberty blockers to be ‘safe’. This is in spite of the impact of sterility from puberty blockers administered in early puberty and followed by cross-sex hormones being recognised since at least 2011, as demonstrated by the UK’s Tavistock Gender Identity Development Service’s protocol for subjects in a study of puberty blockers: ‘The implications of treatment for fertility were discussed at the first and second medical visits and all young people were urged to consider storing gametes before starting GnRHa’. ²⁰ Impaired sexual function was exposed by WPATH president and surgeon Marci Bowers at a conference in 2022 with the statement: ‘Every single child, or adolescent, who was truly blocked at Tanner stage 2 [age 10–12] has never experienced orgasm. I mean, it’s really about zero.’ ²¹

Despite these concerns, AusPATH continued in its Position Statements to declare puberty blockers ‘safe’, and has not sought to retract or urgently update its statements to convey any note of caution. This option was again not taken by AusPATH in March 2024 following the pre-print release of a Mayo Clinic histological study showing evidence of irreversible testicular atrophy in adolescent males on puberty blockers. ²²

Evidence of benefit from puberty blockers

In 2024, AusPATH claimed: ‘the current evidence base supports [puberty blockers] as a safe, effective, and beneficial treatment option’. ⁶ However, as early as 2017, the Endocrine Society Guideline graded the evidence for puberty blockers being used at the start of puberty as being of low quality. ²³ In October 2020, a systematic review by the UK National Institute of Health and Care Excellence found the studies suggesting psychological benefit from puberty blockers to be of ‘very low certainty with the results of studies being of either questionable clinical value and unreliable due to confounding, bias or chance’. ²⁴ In 2022, Finland also sharply curtailed the use of these drugs after their systematic review arrived at similar conclusions about the uncertain risk/benefit profile, ¹⁶ followed by Sweden’s guidelines, based on a systematic review of the evidence, concluding: ‘at present, the risks of hormonal interventions for gender dysphoric youth outweighed the potential benefits’. ²⁵

AusPATH did not take the opportunity to update its position in July 2023, following the Cass Review recommending to the NHS that puberty blockers be restricted to clinical research trials, nor when the Cass Review University of York systematic review found no evidence that puberty blockers improve body image or dysphoria, and ‘very limited evidence for positive mental health outcomes’. ⁵

Buy time to think

As early as 2018, concerns were raised about the high rates of children commenced on puberty blockers continuing on to cross sex hormones (>90%) ²⁶ in view of the known high rate of natural recovery from gender dysphoria through the course of adolescence (61–98%).^27,28 In 2020, the UK High Court recognised that ‘puberty blockers…[are] the first step in a trajectory that almost invariably leads to later prescription of cross-sex hormones with irreversible consequences’. ²⁹ However, AusPATH has never flagged this concern and continues, in 2024, to promote puberty blockers as ‘buying kids and their families extra time to make really important decisions’. ⁶

In direct contradiction of this claim, the Cass Review Final Report concluded that, ‘given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development’. ⁵

Puberty blockers are ‘lifesaving’

In 2024, AusPATH continued to state that puberty blockers were ‘lifesaving’. ⁶ This claim, made without any reliable evidence, is hazardous. It is of grave concern that the risk of death by suicide has been weaponised to coerce parents of gender questioning children to support gender medicalisation’. ³⁰ The Cass Review Final Report concluded: ‘the evidence does not adequately support the claim that gender affirming treatment reduces suicide risk’. ⁵ On 19 July 2024, a Department of Health and Social Care Independent Report reviewed data provided by NHS England on suicides by young patients of UK gender services since the restriction on the prescription of puberty blockers in December 2020. The report concluded: ‘The data do not support the claim that there has been a large rise in suicide in young gender dysphoria patients at the Tavistock’. ³¹

Conclusion

The field of gender medicine has been regarded by some as part of the ‘culture wars’ ³² , however, the long-term consequences of the gender affirming pathway for children and adolescents are profound. If clinicians are taking note of AusPATH recommendations about puberty blockers, they will be dangerously misguided. The field of gender medicine exemplifies the problem in medicine of the chain of trust. No one has enough time to be expert in all the fields they encounter in their practice, and they rely on guidance from people who are considered experts. Gender medicine is a relatively young field. It is certainly poorly evidenced, and the experts are, to a significant extent, self-appointed. ³² AusPATH claims be experts, but their membership consists of whomever wishes to join as a clinician or transgender activist. This approach aligns with RANZCP Position Statement 62: ‘Partnering with people with lived experience’ which acknowledges: ‘Engagement with people who have lived experience in all aspects of mental healthcare has had transformative effects on service delivery and models of care’. The Statement encourages a partnership model. However, it does not include discussion of how to: recruit and integrate voices of people with conflicting lived experience; manage the impact of lived experience on conscious and unconscious processes of communication with health care workers or patients; or balance clinical and research knowledge that conflicts with lived experience accounts.

Until these issues are appropriately addressed, an accurate understanding of the field of gender medicine will require clinicians to go to primary references and apply the principles of evidence-based medicine to analyse papers for validity and reliability. This paper shows that information provided by AusPATH should be critically scrutinised by clinical leaders and developers of health policy, and not just accepted at face value. They should prioritise their patients and families ahead of the sensibilities of activist groups.