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Dr Tracie O’Keefe DCH, sexologist, post grad ADV Dip NSHAP, BHSc, ND., February, 2025

SAGE – Position Paper

SAGE campaigns for the rights and respectful dignity of sex and/or gender diverse (SGD) groups of people in Australia on the issues affecting their everyday lives, and distributes information relating to the quality of their lives. Sex and/or gender diverse people are made up from many differing groups including people who are intersex, transexed, transsexual, transgendered, androgynous, without sex and gender identity, cross-dressers and people with sex and gender culturally specific differences.

Keywords: transexed, transsexual, transgender, sex not specified, gender fluid, sex and gender culturally diverse, puberty blockers and hormones, transgender children, children puberty blockers, trans teenagers, trans youth, sex and/or gender diverse children.

In January 2024 an organisation called ‘Binary’ run by Kirralie Smith, the spokeswoman, sent a letter referring to the sex and gender care for children, with 100 signatures to the Prime Minister Anthony Albanese stating, “potential public health disaster of generational significance that warranted an independent, public investigation”. (1)

Kirralie Smith previously ran a campaign against marriage equality in Australia but after marriage equality was made legal, she rebranded her efforts as Gender Awareness Australia Ltd, Binary Australia. (2)

In late January 2025 the Queensland Health Minister Tim Nicholls announced an immediate pause on access to puberty blockers and hormone therapies for new patients, pending a review, for those under 18 years of age in the public health system. (3) He is a former leader of the Liberal National Party of Queensland.

Concerns were raised about the practices and performance of the Cairns Sexual Health Services clinic, yet the ban was applied statewide, which was alarming and distressing for patients, their families and clinicians.

This was for new patients under 18 years of age. Six hundred minors who were already receiving treatment could continue with treatment.

Mark Butler, the Australian Federal Health Minister, on January 31, 2025, announced a federal review of standards of care into gender-affirming care for trans and gender-diverse children, including the use of puberty blockers. (4)

Butler states he sought consultation with the National Health and Medical Research Council (NHMRC) and the Therapeutic Goods Administration. However, there was no consultation with the client interest group, professional health associations or experts working in the field.

All of this comes off the back of the re-election of President Donald Trump and the suspension of care to trans children in the USA. (5)

This followed the suspension of medical puberty blockers care on the NHS in the UK. Dr Hilary Cass submitted her final report and recommendations to the NHS England in her role as Chair of the Independent Review of Gender Identity Services for Children and Young People. The study suffers from generalisations, selection bias, lack of inclusion of trans voices, selective literature review bias, incomplete diagnostic workup, and interpretation bias. (6)

The Review was commissioned by NHS England to make recommendations on how to improve NHS gender identity services. It was to ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care that meets their needs, is safe, holistic and effective.

The problem with the review is that it was profoundly negatively biased. It warned of the damage that could be done by prescribing puberty blockers to young people and that extreme caution should be exercised. What it did not fully consider was the damage done to people under 18 by denying them that treatment on the NHS.

It ignored the major UK problem of underfunded NHS gender clinics, where the Nottingham clinic, for instance, had a six-year waiting list for an appointment.

The study also suffered from social bias and was classist. Those seeking help through the British government’s health system cannot generally afford the cost of seeking private medicine where puberty blockers and hormones were still available.

Many minors and their families seeking help for severe sex and/or gender dysphoria in Australia face long waiting lists and cannot afford private care, which leaves them without care. Repeated studies have shown this increases the risk of long-term anxiety, depression, social isolation, trauma and suicidal ideation to up to 70% in this population.

These prohibitions are against the advice and policies of the British Medical Council, Royal College of Psychiatry, British Psychological Society, British Counselling and Psychotherapy Association, American Medical Association, American Psychiatric Association,
American Psychological Association, American Counseling Association, Australian Medical Association, Royal Australian and New Zealand College of Psychiatry, Australian College of General Practitioners, Australian Psychological Association, Australian Counselling Association, Psychotherapy and Counselling Federation of Australia, World Professional Association of Transgender Health, Australian Professional Association for Transgender Health, and the Australian College of General Practitioners.

This Queensland ban breaches different Australian and international human rights laws:

The right to medical treatment without prejudice.

The Federal Marriage Act as it does not allow those teenagers to marry as the identity that they believe is right for them.

Breach of freedom to travel freely with a passport that supports a person’s identity.

The right to an education without having to justify one’s sex and gender existence.

The right to work as the sex and gender that befits that person.

What this also does is create a black market from such medications as can be seen in the USA, China, Russia, other countries and widely existed in Australia before Medicare provided services. Such medications can be bought on the dark web and acquired in other countries and smuggled into Australia. So, the ban also puts patients and families in the position of having to break the law to provide help for those teenagers. (7)

Sometimes teenagers who have been taking illegal hormones for years turn up in clinics for help. Director of Gender Services at the Royal Children’s Hospital in Melbourne, Associate Professor Michelle Telfer reported this was the case in their clinic. (8)

Due to waiting lists and economics, those teenagers facing a ban can be secretly taking medication without being medically monitored, which is extremely dangerous. The very idea that those desperate teenagers and family will not do that is pure fantasy. When a teenager is desperate for help and suicidal, they and their parents will take extreme measures.

The idea that there is suddenly a vast influx of vulnerable young people being treated in these clinics is a fallacy. Such young people have always existed in society, it is just that clinicians are now trained and willing to help them. Transition takes years of being monitored and assessed by professionals. The majority of patients who presented to my own clinic did not transition, as on reflection they decided it was not right for them.

I was such a teenager 55 years ago who bought hormones on street corners in London’s Soho at 15 years of age when I could not get help from doctors. Thousands of my peers in different countries did the same, some of whom have died early due to a lack of good medical supervision. This is common practice throughout the world today when clinical help is not available or has been withdrawn. (9) (10) (11).

The danger here is that illegal puberty blockers or hormones may be fake and dangerous. The buyer knows nothing about the seller and what is ingested and injected may be adulterated and dangerous substances, but in desperation the person purchases the unmonitored product. This can result in blood clots, strokes, heart attacks, and pulmonary embolism, osteoporosis, stunted growth, polycythemia, extreme acne and scarring, elevated glucose, liver and kidney failure and cancer, and lowering the intrinsic factor, causing permanent paralysis of the limbs.

We who work with sex and/or gender diverse youth and children have professional standards guided by the World Professional Association of Transgender Health and the Australian Professional Association of Transgender Health. (12) (13). We also are guided by professional standards within our own individual specialties.

There are some mistakes made in any field. The general success rate in treating childhood cancer is around 80%. Sex and gender dysphoria is a rare condition. Medical intervention for it in regards to children has around 38 years of history. It began with the Amsterdam team, under Professor Louis Gooren, the endocrinologist, and the psychologist Peggy Cohen-Kettenis in the 1987. (14) It is an established field of medicine.

Since then the evolution of treatment for minors has moved towards the consent model based on co-operative medicine between patient and clinician, not the oppressive dominating top-down model. What Cohen-Kettenis reported later was that many of her patients who were refused treatment at puberty came back into clinic later, angry and depressed that they had to go through an unwanted puberty.

Therefore, we see by this comparative that the Queensland ban on puberty blockers and hormones is based on transphobia and demonises one specialist field and its patients. No other field is being exposed to these kinds of sanctions. Therefore it is a contravention of the Sex Discrimination Act. (15)

It is a form of body fascism that positions those who present for help with not being strictly male or female as not of sound mind. The same comparative historical harassment has been aimed at gay people, women seeking birth control or abortions and people of different races and abilities. It is a right-wing defence of heteronormative exclusivity.

One of the major problems facing Australian government clinics in the public sector is the lack of financial resources to provide sufficient psychological support for the patients who experience considerable minority stress. Patients can experience bullying, humiliation, social exclusion, threats of violence, exclusion from education and poor responses from medical professionals who have no education in the field.

Puberty blockers are not testosterone or oestrogen but simply delay the onset of puberty, allowing teen children to work out how they want to identify. They can be stopped at any time and puberty continues.

The physiological changes that happen at puberty can be irreversible and are too stressful for the teenagers who do not identify with their registered sex at birth. This leads to trauma, depression and up to a 70% risk of suicidal thoughts and sometimes actions. That trauma can damage many of those children, teenagers and young people psychologically for life. (16)

We also see irrational prejudicial medical comparatives in that someone, for example, with complete Androgyn Insensitivity Syndrome in Queensland would qualify for puberty blockers and hormones under Medicare. However, a teenager with Partial Androgyn Insensitivity Syndrome would not. It is like saying someone with type 1 diabetes should get Medicare rebates, but not someone with type 2, yet both pose serious risks of ill health.

What we also see from these bans is an attempt to re-medicalise sex and/or gender diversity, when in fact it is just a feature of the diversity of nature. It is an attempt to psychiatrically re-pathologise sex and gender diversity and position heteronormative existence as life’s only option. It is cruel and extreme radical prejudice.

Many cultures have perceived sex and/or gender differently, including the First Nations People of Australia. The male/female binary is predominately white colonialism that tried to wipe out concepts of natural diversity and an erasure of cultural identity that continues to this day. We can see from the name of the organisation ‘Binary’, their political agenda is to subvert the principles and protections of the Sex Discrimination Act.

Such exclusionary organisations simply promote denial of the human rights of these young patients. None of the signatories of their letter appear to be experts in the field of sex and gender diversity.

With the suicide and mental health risks that this patient population faces, it is clear puberty blockers and hormones are lifesaving medications that help the young person positively develop in ways that are comfortable for them.

Some Australian politicians or wannabe politicians seek to score political points by trying to paint clinicians in this field as Dr Frankenstein and the patients as disaffected and delusional. We are dedicated health professionals with decades of training, doing the best we can for our patients and clients according to ethical guidelines to prevent the complications of sex and gender dysphoria.

As sex and/or gender diverse people, we are doctors, psychiatrists, nurses, dentists, psychologist, counsellors, teachers, professors rocket scientists, mathematicians, computer engineers, lawyers, judges, politicians, novelists, ethicists and from all walks of life. We are not delusional and demand the respect afforded by other members of society as children and adults.

The head of the Australia Human Rights Commission Dr Anna Cody has raised concerns on the ban in Stage One and Two hormone therapies for people under 18 through the Queensland’s public health system. She said suspending those services during a review was dangerous. (17)

Judith Butler, the American feminist philosopher said, “If you sacrifice a minority like trans people you are operating within a fascist logic.”

We can see that families and patients in the USA have launched lawsuits against Donald Trump’s executive order prohibiting gender care. The challenges of these executive orders is that the federal government has no power to suspend the medical care of minority groups and is discriminatory. (18)

A parallel can be drawn to Australia in that the Queensland ban on puberty blockers and hormones for trans people under 18 is discriminatory. This makes it illegal under the Sex Discrimination Act.

Treatment should be restored for these patients as soon as possible to avoid irrevocable damage to their lives.

References

1. Smith, K. (2025, January 30). 100 prominent Australians sign letter to stop harmful gender practices. Binary Australia. https://www.binary.org.au/100-prominent-australians-sign-letter-to-stop-harmful-gender-practices
2. Star Observer. (n.d.). Anti-marriage equality org rebrands as anti-trans group Binary Australia. https://www.starobserver.com.au/news/national-news/anti-marriage-equality-org-rebrands-as-anti-trans-group-binary-australia/173664
3. Nicholls, T. (2025). Independent review into puberty blockers. Minister for Health and Ambulance Services. https://statements.qld.gov.au/statements/101903
4. Australian Government Department of Health and Aged Care. (n.d.). Health care for trans and gender diverse Australian children and adolescents. https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/health-care-for-trans-and-gender-diverse-australian-children-and-adolescents?language=en
5. ABC News. (2025, January 29). Donald Trump signs executive order ending U.S. funding for children’s gender-affirming care. https://www.abc.net.au/news/2025-01-29/trump-orders-end-to-gender-affirming-care-children-us/104870554
6. Cass, H. (2024). The Cass Report: Final report on gender services for children and young people. https://cass.independent-review.uk/home/publications/final-report/
7. The Guardian. (2024, May 3). Concerns as cross-sex hormones available online for just £11 a month. https://www.theguardian.com/society/article/2024/may/03/cross-sex-hormones-available-online-11-pounds-a-month-young-people-gender-identity
8. ABC News. (2016, August 15). Transgender teenagers ‘risking lives’ buying hormones on black market. https://www.abc.net.au/news/2016-08-15/transgender-teens-buying-black-market-hormones/7722084
9. Kirey-Sitnikova, Y. (2023). Access to gender-affirming hormonal therapy in Russia: Perspectives of trans people and endocrinologists. International Journal of Transgender Health. https://www.tandfonline.com/doi/full/10.1080/26895269.2023.227214
10. Olansky, E., Lee, K., Handanagic, S., & Trujillo, L. (2024, January 25). Nonprescription hormone use among transgender women — National HIV Behavioral Surveillance among transgender women, seven urban areas, United States, 2019–2020. Morbidity and Mortality Weekly Report, 73(1), 34–39. https://www.cdc.gov/mmwr/volumes/73/su/su7301a4.htm
11. (2023). How a new drug law, old attitudes, and persistent health care system shortcomings threaten China’s transgender community. https://time.com/6261675/china-transgender-hormones-black-market/
12. World Professional Association for Transgender Health (WPATH). (2023). Standards of care for the health of transgender and gender diverse people, Version 8. https://wpath.org/publications/soc8/
13. Australian Professional Association for Trans Health (AUSPATH). (2024). Australian standards of care and treatment guidelines for trans and gender diverse children and adolescents. https://auspath.org.au/2018/02/01/https-auspath-org-au-wp-content-uploads-2024-02-230242-rch-gender-standards-booklet-1-4_nov-2023_web-final_-pdf/
14. Carswell, J. M., Lopez, X., & Rosenthal, S. M. (2022). The evolution of adolescent gender-affirming care: A historical perspective. Hormone Research in Paediatrics, 95(6), 649–664. https://doi.org/10.1159/000528500
15. Sex Discrimination Act 1984, No. 4 (1984). Compilation No. 46. Compilation date: 14 October 2024. Australian Government. https://www.legislation.gov.au/Details/C2024C00123
16. O’Keefe, T. (2021). Suicide in intersex, trans and other sex and/or gender diverse groups: A health professional’s guide.   https://www.amazon.com/Suicide-Intersex-Gender-Diverse-Groups/dp/0987510959
17. Australian Human Rights Commission. (n.d.). Sex Discrimination Commissioner raises concerns on Queensland’s pause on hormone therapies. https://humanrights.gov.au/about/news/media-releases/concerns-queenslands-pause-hormone-therapies
18. Trans young adults and parents sue over Trump’s orders restricting transition care, NBC News, 2025 https://www.nbcnews.com/nbc-out/out-politics-and-policy/trans-young-adults-parents-sue-trumps-orders-restricting-transition-ca-rcna190617