Children as young as 12 were prescribed puberty blockers without appropriate assessment, a scathing review of the Cairns paediatric gender health service has revealed.
The 213-page review, commissioned by Queensland Health director-general David Rosengren more than a year ago, highlighted a “negative patient safety culture” at the service.
“Incident reporting, risk management and audit processes were either absent or inconsistently applied with limited review of adverse events or complaints and little evidence of continuous quality improvement,” the review found.
Lacking capacity
Investigators outlined staff reports about young people with developmental delays being on medication “despite lacking capacity to understand treatment information”.
“There were cases where paediatric patients moved from psychology to hormone treatment within weeks, without a consistent process for family engagement or education,” they found.
The review was commissioned by Queensland Health director-general David Rosengren more than a year ago. (ABC News: Conor Byrne)
Informed consent was “not consistent with best practice,” the report said, and clinical documentation was often “not complete”.
“Treatment in some cases commenced before formal consent was obtained,” the reviewers found.
“The informed consent process did not meet the service’s legal obligations or national standards.”
A review in December 2024 of 17 patient records showed “major deficiencies”, including incomplete clinical notes, missing tests, absence of consent documentation and a lack of mental health input.
It found “little evidence” of consistent documentation of competency assessments.
Snap new Queensland ban on puberty blockers for transgender youth
“In many cases, they were either not done or not recorded,” the investigators found.
The Cairns paediatric gender health service had been treating patients under the age of 18 for gender dysphoria from at least 2008, “and possibly earlier.”
“As the service evolved gradually, it was not subject to the greater rigour and structured oversight of a newly implemented service,” the reviewers said.
The review found there were anecdotal reports in 2018 from senior medical staff regarding “misdiagnosis of patients with gender dysphoria when they had mental health conditions” and comments suggesting non-adherence to guidelines.
“Instead of triggering closer scrutiny of adherence to guidelines, the issue wasn’t followed up,” the report said.
The reviewers found risks identified in the Cairns service were not “appropriately escalated” to the executive and board before mid-to-late 2024 and therefore not monitored or controlled at the executive or board level.
In May of that year, a clinician told the Cairns and Hinterland Hospital and Health Service executive of an attempt by staff to prescribe the puberty blocker Lucrin “outside state guidelines”. It was refused by the pharmacy.
The review found there were concerning anecdotal reports in 2018 that were not followed up. (ABC News: Conor Byrne)
Two months later, a directive was issued that all children must be referred to the Brisbane-based Queensland Children’s Gender Service for review before starting puberty blockers.
Concerns over treatment sparked an initial review of the service in late 2024, with Dr Rosengren ordering a health service investigation in January 2025.
That same day, Health Minister Tim Nicholls announced an “immediate” statewide pause on new adolescent patients with gender dysphoria receiving puberty blockers or gender-affirming hormones in the public health system, pending the outcome of a separate investigation into the evidence base of such treatments.
That investigation, by former Victorian chief psychiatrist Ruth Vine, prompted Mr Nicholls to extend the ban until the outcome of a UK trial into the effects of puberty blockers on young people, not expected before 2031.
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The review into the Cairns paediatric gender service said staff wellbeing was “compromised by leadership instability”, inadequate support, a culture of fear, and poor communication, which collectively eroded psychological safety, professional trust and the ability to deliver safe, effective care.
It found the workforce did not “reflect the specific expertise required” for the child and adolescent patients and hormone prescribing.
The investigators said some clinical tasks within the paediatric gender health service were “inappropriately delegated to non-clinical staff”.
They made 21 recommendations, including that the Cairns health service should not undertake initial assessment or diagnosis of gender dysphoria in young people aged under 18.
Queensland Health director-general David Rosengren. (ABC News: Mark Leonardi)
It also recommended that the health service conduct an audit of all gender dysphoria patients who were under 18 between 2018 and 2021.
In a statement, Dr Rosengren said Queensland Health accepted the recommendations “in principle”.
He said specific concerns around individual clinical practice — that have been identified during the clinical review — have been referred to the Office of the Health Ombudsman.