For Oficial Use Only (FOUO)
FOI 4876 - Document 14
MSAC Executive Teleconference
Date: Friday, 26 May 2023
Toll Dial-in: s47F
Time: 12.00pm – 2.00pm
Participant passcode: s47F
Agenda Item 5.6: New MSAC application 1754 - Patient consultations and
surgical procedures for gender affirmation in adults with gender
incongruence
Consulted:
s22
Medical Officer, TAAD
Medical Officers, MBD
s
2
2
UNDER CARE
Medical Specialist Services Section, MBD
1982
s
AGED
2
ACT
2
RELEASED AND
Presenter:
BEEN
s22
HTA Adviser, MSAC Assessment Section
HEALTH
HAS
OF
Purpose:
INFORMATION
To seek MSAC Executive advice on the appropriate health technology assessment (HTA)
OF
assessment and pathway for MSAC application 1754.
Background:
DOCUMENT
The Australian Society of Plastic Surgeons Inc. (ASP
DEPARTMENT
S) has submitted an MSAC application
FREEDOM
proposing a suite of Medicare Benefits Schedule (MBS) consultation items (including health
THIS
assessments, patient consultations a
THE nd multidisciplinary care conference items) and surgical
THE
items (
Attachment A and
At
BY
tachment B). Also separately proposed are changes to PBS listed
medicines used in the management of gender affirmation but are not encompassed by the MSAC
application.
MSAC Executive advice has previously been sought regarding the appropriate pathway for the
consideration of a suite of gender affirmation MBS items. At the July 2022 MSAC Executive
meeting, the MSAC Executive were provided a s47C
high-level overview of a suite of proposed MBS items for gender affirmation and were asked to
advise whether:
s
4
7
C
1
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FOI 4876 - Document 14
In summary, the MSAC Executive’s advice at that time was (see
Attachment C):
• Considered that the current MSAC process was suitable for appraisal of the application
and did not consider that a specialist clinical committee was required.
• Accepted that the evidentiary basis to support the proposed items was likely to be limited.
• Requested the Department seek further clarification on what quality control measures
will be implemented by the ASPS to regulate their members and ensure the safety of
their patients in the event of surgery failures.
• Considered that a multi-disciplinary best model of care framework extending before and
after any surgery was needed and that improving existing services and developing a
framework of support could be a potential alternative to developing new MBS items.
Issue:
1. Ministerial correspondence
The Minister and the Department receive a number of enquiries from patients regarding the out-
of-pocket costs of gender affirmation procedures. In these enquiries patients have reported facing
high out of pocket costs for private gender affirmation surgery, up to $50,000.
CARE
A number of petitions have also been lodged with the House of Represe
UNDER ntatives to request
Medicare funding for gender affirmation surgery, most notably in June 2021 Petition EN3307 -
1982
Gender affirming surgery should be covered by Medicare received 148,182
AGED signatures. Previous
Minister Greg Hunt’s published responses to these petitions have been that an MSAC application
ACT
would be required for consideration of an MBS item/s for gender af
AND firmation surgery.
RELEASED
s47C
BEEN
HEALTH
HAS INFORMATION
OF
2. Safety and quality control measures (previously raised by MSAC Executive)
OF
s47C
DOCUMENT
FREEDOM
DEPARTMENT
The application (pg 11 of
Attachment B)
does propose that the MBS items for gender affirming
THIS
interventions are limited to medic
THE al practitioners that are registered specialists (would have met
THE
the training and qualification requirements set out by their professional board).
BY
The application also references ‘Standards of Care for the Health of Transgender and Gender
Diverse People, Version 8’1. Chapter 13 – Surgery and postoperative care, describes a spectrum
of gender-affirming surgical procedures for the diverse and heterogeneous community of
individuals who identify as transgender. It makes 11 statements of recommendation and provides
a discussion about the optimal surgical training in gender-affirmation surgery procedures, post-
surgical aftercare and follow-up, access to surgery by adults and adolescents, and individually
customised surgeries.
The application notes that the above referenced standards of care have been endorsed as a
Standard of Care by the Australian Professional Association for Trans Health (AusPATH) but
does not state whether (and how) the ASPS intend to implement any measures to regulate their
members and ensure the safety of their patients in the event of surgery failure.
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FOI 4876 - Document 14
3. Proposed best model of care (previously raised by MSAC Executive)
s47C
Of note, there is a current MRFF Grant Opportunity assessing the optimal models of care for
“Sexuality & Gender Diverse People & People with Innate Variations of Sex Characteristics”,
seen at:
https://www.grants.gov.au/Go/Show?GoUuid=e69dca85-1fcb-4e39-872d-b1ced05bb58b
The MSAC Executive may wish to advise, s47C
CARE
UNDER
4. Overlap of proposed and existing consultation items
1982
AGED
s47C
ACT
RELEASED AND
The Department considers that the listed existing items provide for the services proposed by the
BEEN HEALTH
applicant, and that new consultation items are not required for this specific patient group.
HAS INFORMATION
OF
The Department notes that the applicant has requested specification of the patient group in the
explanatory notes accompanying the health a
OF ssessment (701, 703, 705, 707) and chronic disease
management (CDM) items (721, 723, 729 and 732). This patient group can currently access the
CDM items where the treating general practitioner (GP) assesses the person has a chronic
DOCUMENT
condition and would benefit from a management plan and/or multidisciplinary team care. It is the
DEPARTMENT
Department’s position not to specify eli
FREEDOM gible conditions due to the risk of excluding access to
THIS
particular groups inappropriately. This patient group are not currently eligible for health
THE THE
assessments unless they also fall into an eligible category. s47C
BY
. The Department’s perspective
is that any such consideration of the consultation items can be undertaken separately to the
consideration of the surgical items and this division would not impact the options put forward for
the HTA and pathway for the surgical items.
5. Overlap of proposed and existing surgical items
s47C
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FOI 4876 - Document 14
s47C
6. Utilisation of existing items for gender affirmation surgery
The Department understands that there is already some use of the existing MBS surgical items
for gender affirmation surgery. However, due to the lack of reporting describing item use by
indication, it is not feasible to determine the accurate extent of utilisation in the proposed
population. Any assessment would require assumptions based on clinical expert opinion to
estimate the potential current utilisation of existing MBS surgical items for gender affirmation
surgery.
CARE
s47C
UNDER
1982
AGED
ACT
7. Estimated utilisation
RELEASED AND
The application estimated that in 2023 there are approximately 128,145 transgender people
(assumed 1.05%2 of the population) that would be eligible for gender affirming surgery and that
47,087 primary gender affirming surgeries would be
BEEN accessed from the range of available
HEALTH
procedures (pg 7/14 of
Attachment A).
HAS INFORMATION
OF
The applicant determined the estimated number of surgeries by applying uptake percentages to
OF
the eligible population for each gender affirmation surgery type (i.e., gender affirming chest
surgery, genital reconfiguration surgery, gender affirming facial surgery and gender affirming
voice surgery). The estimated number of surgeries is not a 1:1 estimate of the number of eligible
DOCUMENT
individuals who may undergo gender affirming surgery (i.e. one individual may have more than
FREEDOM
DEPARTMENT
1 of the gender affirming surgical procedures in each category). The uptake rates were based on
THIS
the percentage of gender affirming surge
THE
ries reported in a retrospective audit of 540 Australian
THE
transgender individuals3.
BY
The applicant’s utilisation estimates over 6 years have assumed a constant uptake rate s47C
A 2021 metanalysis of 7928 individuals who underwent gender affirmation surgery identified
approximately 1% as having post-surgery regret (categorised as minor or major).4
8. Cost-effectiveness of the comparator has not been established
The existing MBS surgical items (comparator) were included on the MBS prior to the
establishment of the MSAC and as such the none of the individual items comprising the
comparator have undergone an HTA to establish cost-effectiveness. Any HTA comparing the
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FOI 4876 - Document 14
s47C
9. HTA for revision items
The Department notes that for the comparator, there are no specific revision items rather revision
is likely to be performed under the initial surgery item.s47C
No revision surgery item descriptors, or fee,
were proposed by the applicant s47C
Department Position
The Department notes the below three options for progressing the application.
Option 1 – s47C
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
Option 2 –s47C
HAS
INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
Table 1: High-level summary of Department proposed s47C
Component
Description
Department comments
s47C
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FOI 4876 - Document 14
The application states the diagnosis of gender
s47C
incongruence would be made a person’s
managing clinician, usually a general
practitioner, but sometimes by a sexual health
practitioner, endocrinologist or psychiatrist. The
diagnostic criteria are outlined in the
International Classification of Diseases 11th
Revision maintained by the World Health
Organization (pg 1/35 of
Attachment B).
s47C
(2) Individuals requiring revision of primary
surgical procedures for gender affirmation –s4
7C
Is47C
CARE
UNDER
1982
AGED
ACT
AND
RELEASED
BEEN
HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
DEPARTMENT
FREEDOM
THIS
THE THE
BY
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FOI 4876 - Document 14
s47C
CARE
UNDER
1982
AGED
ACT AND
RELEASED
BEEN HEALTH
Option 3 – s47C
HAS
INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
Limitations and risks
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FOI 4876 - Document 14
Table 2: Advantages, limitations and risks identified for each Option
Option 1 – s47C
Option 2 – s47C
Option 3 – s47C
Advantages s
4
7
C
Limitations and risks
s47C
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN
HEALTH
HAS
OF
INFORMATION
OF
s47C
Same as Option 2
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE
THE
BY
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FOI 4876 - Document 14
and effectiveness
s47C
s47C
Same as Option 1
Same as Option 1
UNDER CARE
1982
AGED
ACT
AND
RELEASED
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS THE
THE
s47C
Same as Option 2
BY
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FOI 4876 - Document 14
s47C
Action: The MSAC Executive to:
•
Note an updated MSAC application has been submitted and s47C
• s47C
issue requires further information, development and/or consideration by
clinical experts.
•
Note the limitations and risks for each option.
•
Advise the Department s47C
Author: s22
MSAC Assessment Section, OHTA Branch, TAAD
UNDER CARE
Medical Officer clearance: s22
Medical Officer, TAAD
Assistant Secretary clearance:
1982
AGED
• Natasha Ploenges, Office of Health Technology Assessment Branch
•
ACT
Nigel Murray, MBS Policy and Specialist Services Branch
RELEASED AND
Attachments:
A – MSAC 1754 Application Summary
BEEN HEALTH
B – MSAC 1754 Application PICO Set
OF
C – Excerpt of July 2022 MSAC Executive Minu
HAS
tes for Item 5.5 Gender Affirmation
INFORMATION
D – Department summary of gender affirmation surgery items and clinical algorithm
OF
E – Department summary of patient and multidisciplinary consultation items
References:
DOCUMENT
1. Coleman et al. (2022). Standards of care for the health of transgender and gender diverse
FREEDOM
DEPARTMENT
people, version 8. International Journal of Transgender Health 23(sup1): S1-S259.
THIS
2. Cheung et al. (2019). Posit
THE ion statement on the hormonal management of adult
THE
transgender and gender diverse individuals. Medical Journal of Australia 211(3): 127-133
BY
3. Cheung et al. (2018). Sociodemographic and clinical characteristics of transgender adults
in Australia. Transgender health 3(1): 229-238
4. Bustos et al. (2021). Regret after Gender-affirmation Surgery: A Systematic Review and
Meta-analysis of Prevalence. Plastic and Reconstructive Surgery - Global Open 9(3):
e3477.
< End of paper >
10
FOI 4876 - Document 15
Attachment C - Excerpt from MEDICAL SERVICES ADVISORY COMMITTEE
(MSAC)
EXECUTIVE Teleconference
Friday 1 July 2022, 12:00pm – 2:00pm
FINAL Minutes – Ratified 31 July 2022
5.5: Australian Society of Plastic Surgeons (ASPS) proposal for suite of gender
affirmation MBS items and PBS medications
The MSAC Executive noted the Department sought advice on an appropriate pathway for the
consideration of a suite of MBS items related to gender affirmation, submitted within a wider
proposal to the Department by the Australian Society of Plastic Surgeons (ASPS) (the
applicant). The intent of the proposed MBS items is for people experiencing gender
incongruence1 to have publicly funded access to medical gender-affirming care (for those
who seek it). In addition to attendance items with specialists such as GPs, sexual health
physicians, endocrinologists and psychiatrists, most of the proposals by the applicant aim to
UNDER CARE
establish MBS items specifically for gender-affirming surgeries. The MSAC Executive noted
that the applicant has established the Australian Collaborative on Ac
1982 cess to Gender Affirming
AGED
Medical Services (ACA-GAMS) to assist the development and progress of the proposal. s47
ACT
C
RELEASED AND
The MSAC Executive noted the Department’s adv
BEEN ice that while there are no specific MBS
HEALTH
items for gender-affirming surgery there are items that provide for a range of surgical
OF
procedures and specialist attendances simi
HAS lar to what has been proposed, that may be utilised
INFORMATION
currently to assist people seeking gender-affirming medical care. However, the applicant
OF
advised that uncertainty exists in the sector regarding the appropriateness of billing these
existing items and concerns had been raised that the implementation of certain changes to
plastic and reconstructive surgery items from 1 November 2022 would limit access further.
DOCUMENT
The Department advised that this change was in r
DEPARTMENT elation to amendment of item 45563. The
FREEDOM
MSAC Executive also noted that a disadvantage with the existing MBS items is the inability
THIS
for the Department to mea
THE sure uti
THE lisation for the purposes of gender-affirming medical care.
BY
The MSAC Executive noted that the applicant proposed establishment of a dedicated clinical
committee to consider and develop the MBS items, similar to those created by the MBS
Review Taskforce, due to the complexity and variation in delivering gender-affirming
medical care. The MSAC Executive considered that the current MSAC process was suitable
for appraisal of the application and did not consider that a specialist clinical committee was
required. The MSAC Executive accepted that the evidentiary basis to support the proposed
items was likely to be limited.
1 ICD-11 https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f411470068
FOI 4876 - Document 15
The MSAC Executive noted there is increasing consumer interest and demand for access to
publicly funded gender affirming medical services in Australia. The MSAC Executive noted
that gender reassignment surgeries are varied, involve different surgical specialities, are
technically complex, and dependent on the individual desires of the person seeking it. The
MSAC Executive also noted that people seeking these surgeries represent a very small
proportion of the population and there are limited surgeons practicing in the field of gender-
affirming medical care in Australia. The MSAC Executive acknowledged that people seeking
gender reassignment surgeries may opt for medical tourism in other countries where surgery
is less expensive, more readily available and less regulated than in Australia.
The MSAC Executive considered that strong quality control measures were required if this
proposal for gender-affirming surgeries was publicly funded in Australia. s47C
The MSAC Executive noted that assurance of
safe and effective service for gender-affirming medical care was not just limited to gender-
affirming surgeries but needed a multi-disciplinary best model of care framework extending
before and after any surgery. The MSAC Executive considered that improving existing
services and developing a framework of support could be a potential alternative to developing
CARE
new MBS items.
UNDER
1982
The MSAC Executive advised that this proposal should undergo assessmen
AGED t through the
standard HTA pathway to MSAC. The MSAC Executive considered the application should
ACT AND
include the proposed best model of care for people experiencing gender incongruence seeking
RELEASED
gender-affirming medical care. The MSAC Executive considered that any form of public
funding for the provision of gender-affirming medical care should include an
BEEN
interdisciplinary care model to ensure the best quality care pa
HEALTH ckage is provided for the
individual.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 17
Patient Discharge Multidisciplinary
Consultant Physician led Discharge Multidisciplinary care Existing items considered appropriate for the proposed service
conferences
conference (Organise (830, 832, 834), Attend (835, 837,
838))
Currently there are no discharge conference items for specialists on the MBS, as opposed to
consultant physicians for which there are existing items for this service. The Department will work
Psychiatrist led discharge Multidisciplinary care
further with the applicant to determine if their proposal is that specialists have access to discharge
conference (Organise 861, 864, 866), Attend 835, 837, items for patients undergoing a gender affirmation process which would require a broader MBS
838))
consideration.
Post treatment follow-up consultations
Specialist Patient consultations (104, 105)
Existing items considered appropriate for the proposed service
provided to patients by a single medical
practitioner (e.g., follow-up for surgery-
Consultant Physician Patient consultations (110, 116)
related complications after gender
Sexual health practitioner patient consultations (6051,
affirmation surgery)
6052, 6057, 6058)
Psychiatric patient consultations (291, 293, 296, 300,
302, 304,306)
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 18
MSAC Executive
Medical Specialist Services Section
MBS Policy & Specialist Program Branch
Medicare Benefits and Digital Health Division
P: s47E(d)
15 Aug 2023
Dear MSAC Executive,
Thank you for your considered letter about our application for MBS items for gender affirming care.
We note that the Department has been very generous with its time in considering the matters around this
application. ASPS requests that this application now goes to the PASC meeting of the 7th/8th December and
we will be available to attend to answer further questions and assist as needed.
UNDER CARE
In relation to the summary points on the first page:
1982
AGED
ACT
ASPS accepts that the standard HTA / MSAC process will be employed and lo
AND
ok forward to
RELEASED
constructively working within that framework.
Although evidence in this area is less than for some other areas of health, evidence is quickly
BEEN
building and members of our collaborative team are actively inv
HEALTH olved in research in this area.
Should this application be successful, separate
HAS
item numbers for p
OF
rocedures for people with
INFORMATION
gender incongruence will greatly facilitate high quality research, and our group are strongly
OF
considering applying for an MRFF grant to monitor the results of healthcare changes in this area.
In regards to “regulation of our members”, ASPS would like to clarify that we are a not-for-profit
society of members, not a regulatory body. However, our organisation promotes education of
DOCUMENT
members and does have a strong ethical framework
DEPARTMENT
with an associated ethics committee. In terms
FREEDOM
of “quality control”, ensuri
THIS
ng that providers performing this surgery are “specialists working in the
THE
field of their specialty” is likely to be desirable.
THE
The surgical Specialty Colleges have extensive non-
BY
technical and ethical training and ongoing governance and guidelines for their Fellows.
ASPS agrees that a multidisciplinary team approach is appropriate as long as it is not constructed in
a way that is cumbersome and a significant limit to timely and appropriate access to care.
Involvement of the primary care physician is also crucial. Our proposal of expanding the “medical
assessment” item xxxx to have gender incongruence as a defined group, we believe is a very good
step for holistic care close to home. If it is then supplemented by an MDT that could be hybrid in
model (videoconferencing and face to face) then we feel this would meet the needs of patients.
The arguments against expansion of the “medical assessment item xxx” are understandable
(slippery slope of more and more groups wanting this status) but are outweighed by the safety and
holistic care benefits for this particularly vulnerable section of the population.
In regards to developing best practice models of care
instead of seeking item numbers, we regard
this as inappropriately further delaying access to care for those who urgently need it. There are
already multiple models of care co-existing in Australia for gender affirming surgery and several
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
OFFICIAL: Sensitive
FOI 4876 - Document 19
MEDICAL SERVICES ADVISORY COMMITTEE (MSAC)
EXECUTIVE Teleconference
Friday 26 May 2023, 12:00pm – 2:00pm
FINAL Minutes – Ratified 26 July 2023
Excerpt Agenda item 5.6
5.6: New MSAC application 1754 – Patient Consultations and Surgical Procedures for
Gender Affirmation in Adults with Gender Incongruence
The MSAC Executive noted the department sought advice on the appropriate HTA pathway for
MSAC Application 1754 –
Patient consultations and surgical procedures for gender affirmation
in adults with gender incongruence if the application received from the Australian Society of
Plastic Surgeons Inc. (ASPS) meets the suitability requirements for the MSAC process.
The MSAC Executive recalled that its advice was sought by the department at the 1 July 2022
MSAC Executive meeting regarding the appropriate HTA pathway for the consideration of a
suite of gender affirmation Medicare Benefits Schedule (MBS) items that had been proposed by
the ASPS in a sample (partially completed) application. Following this initial engagement with
the department last year, the ASPS has now submitted MSAC application 1754 proposing a suite
of MBS consultation items (including health assessments, patient consultations a
CARE nd
UNDER
multidisciplinary care conference items) and primary and revision surgical items to support
1982
gender affirmation in adults with gender incongruence. The MSAC Exe
AGED cutive noted the
applicant has been advised by the department to submit a separate application to the
ACT
Pharmaceutical Benefits Advisory Committee (PBAC) proposing c
AND hanges to PBS listed
RELEASED
medicines used in the gender affirmation of adults with gender incongruence and that access to
medications will not be considered through the MSAC process.
BEEN HEALTH
The MSAC Executive recalled the advice it provided at the 1 July 2022 meeting in summary as:
HAS INFORMATION
OF
• The MSAC Executive considered that the current MSAC process was suitable for
OF
appraisal of the application and did not consider that a specialist clinical committee was
required to be formed to perform a HTA of the proposed application.
• The MSAC Executive accepted tha
DOCUMENT
t the evidentiary basis to support the proposed items
DEPARTMENT
was likely to be limited.
FREEDOM
• The MSAC Exec
THIS utive requested the department seek further clarification on what quality
THE THE
control measures will be implemented by the ASPS to regulate their members under the
BY
surgical items and ensure the safety of their patients in the event of need for surgical
revision.
• The MSAC Executive considered that a multi-disciplinary best practice model of care
framework extending before and after any surgery was needed and that improving
existing services and developing a framework of support could be a potential alternative
to developing new MBS items.
The MSAC Executive recalled that this previous advice had been provided based on an
incomplete sample application and noted other issues, in addition to those already raised above,
have been identified by the department during the current suitability assessment of application
1754.
• The ASPS did not explicitly address in application 1754 what quality control measures
will be implemented to regulate their members and ensure the appropriate management
and safety of their patients where adverse events to occur following surgery. Although,
the application did:
1
OFFICIAL: Sensitive
FOI 4876 - Document 19
o propose that the MBS items for gender affirming interventions are limited to medical
practitioners that are registered specialists; and
o reference the ‘Standards of Care for the Health of Transgender and Gender Diverse
People, Version 8’1 which has been endorsed by the Australian Professional
Association for Trans Health (AusPATH) and includes recommendations (Chapter
13) on surgical training, post-surgical aftercare, access to surgery and individually
customised surgeries.
• The ASPS claim that the requested MBS consultation and surgical items would
collectively facilitate a multidisciplinary best practice model of care framework for
patients that extends before and after any surgery. There is also a current MRFF grant
opportunity assessing the optimal models of care for “Sexuality & Gender Diverse
People & People with Innate Variations of Sex Characteristics”2.
• The department considered that the new consultation items proposed by the applicant are
not required as they appear to overlap with existing consultation items. The applicant has
proposed specification of the patient group in the explanatory notes accompanying the
health assessment and chronic disease management items, however the department’s
position is to not specify eligible conditions due to the risk of excluding access to
particular groups inappropriately. These patients would generally be eligible for the
current chronic disease management items including GP management plan, team care
arrangements and related allied health services. They are not specifically eligible for the
existing Health Assessment items and they would only be eligible for these
CARE
if they met
UNDER
the criteria for another specific condition. Note that the health assessment items are
1982
currently under review.
AGED
• The department considered that the proposed surgical MBS items would meet the MBS
ACT
requirements for clinically relevant and necessary services a
AND nd that the proposed surgical
RELEASED
MBS items (for primary procedures) overlap with existing surgical items. However, the
department considered that the policy intent of the existing items differed to the purpose
BEEN
sought in the application. The department also noted ther
HEALTH
e are no specific revision items
for the existing MBS surgical items, and that the primary surgical item is generally used
HAS INFORMATION
OF
for revision.
• The utilisation of existing MBS surgic
OF
al items in the proposed population is unknown
due to lack of reporting describing item use by indication and any assessment would
require assumptions based on clinical expert opinion to estimate the potential current
utilisation of existing MBS surgic
DOCUMENT
al items for gender affirmation surgery. The department
DEPARTMENT
considered the use of surgery pe
FREEDOM rformed overseas, or privately without use of MBS
THIS
reimbursement in Australia, to be out of scope of an HTA for this application.
THE
•
THE
The estimated utilisation for gender affirming surgeries in application 1754 is highly
BY
uncertain. The department highlighted that a robust estimate of utilisation will be
challenging due to limited evidence to reliably inform the proportion of patients who will
elect to undergo gender affirming surgery and that predicting future utilisation will be
challenging as this is likely to be influenced (unknown magnitude) by perceptions and
acceptance of gender affirming surgery. In addition, due to differences in individual
preferences, there is likely to be wide variation in which gender affirming surgery(ies) (if
any) a patient elects to undergo. Assuming patients would access the full suite of gender
affirming surgeries may over-estimate the costs to the MBS and while sensitivity
analyses could explore the assumptions used this may not reduce the uncertainty.
1 World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender
and Gender Diverse People, Version 8, (2022)
International Journal of Transgender Health, 23:sup1, S1-
S259, DOI: 10.1080/26895269.2022.2100644, Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9553112/pdf/WIJT_23_2100644.pdf
2 https://www.grants.gov.au/Go/Show?GoUuid=e69dca85-1fcb-4e39-872d-b1ced05bb58b
2
OFFICIAL: Sensitive
FOI 4876 - Document 19
• The nominated comparator (existing MBS surgical items) encompasses a number of
surgical procedures that are well-established in clinical practice which did not undergo an
HTA assessment before MBS listing. As such, there are likely to be challenges with the
level of contemporary evidence for the comparator. In addition, the cost-effectiveness of
the comparator will need to be established before the comparative safety, effectiveness
and cost-effectiveness of the intervention can be assessed. Consequently, the likely
limitations and uncertainty in the clinical evidence may create high uncertainty in the
comparative safety, effectiveness and cost-effectiveness assessments.
• There is a lack of information in the application as to what the proposed revision items
would encompass and lack of information on the utilisation of these potential items. At
this stage, an HTA for the revision procedure items is not considered feasible and can be
considered subsequent to the assessment of the proposed primary procedure items, as a
separate issue.
The MSAC Executive acknowledged all the issues, uncertainties, limitations and risks with the
application and any HTA for the proposed MBS items. The MSAC Executive deliberated on
whether the MBS items proposed in application 1754 would support a multidisciplinary best
practice model of care framework for patients.
The MSAC Executive considered the advantages with having dedicated surgical item numbers
for gender affirmation surgeries noting that data collecting would be unambiguous
CARE
compared to
UNDER
using existing items where the indication for the service being claimed is not recorded. Specific
item numbers would allow for the specification of pre-requisite servic
1982 es or consultations,
AGED
including the involvement of other specialties or allied health professionals.
ACT
RELEASED AND
Furthermore, the MSAC Executive considered that this proposal should be considered via a
holistic person-centred approach. The MSAC Executive noted that surgical intervention for this
population was only one aspect of supporting ge
BEEN nder affirmation in adults with gender
HEALTH
incongruence. The MSAC Executive considered an approach which is person-centred and
HAS
OF
involves a multidisciplinary team may reduce the risk of
INFORMATION harm to patients and assist in reducing
the need for revision surgery. The MSAC Executive strongly reiterated their previous advice that
OF
these persons need to be managed in a multidisciplinary team noting the very individual
experience of each person given the composite of multivariate interventions per individual.
DOCUMENT
The MSAC Executive considered that further cons
DEPARTMENT ideration and consultation should be
FREEDOM
undertaken to ensure that
THIS gender affirming surgical services are provided within a patient-
THE
centred and multidisciplina
THE ry best practice model of care framework. The MSAC Executive
considered the MBS item m
BY odel alone may not meet the needs of patients and that a funding
avenue that delivered a multidisciplinary framework could be explored by the department. The
MSAC Executive considered that the department could undertake this policy work in parallel to
the application.
The MSAC Executive also noted that of the people who undertake gender affirmation surgery,
many choose to do so overseas, and did not want to disincentivise individuals seeking services
that can be delivered appropriately and safely domestically. The MSAC Executive
acknowledged there will be a high level of public interest in this application, highlighted by the
ongoing enquiries to the Minister and department regarding the out-of-pocket costs of gender
affirmation procedures and petitions lodged to the House of Representatives requesting
Medicare funding for gender affirmation surgery. The MSAC Executive considered that MBS
item numbers for the provision of surgical services alone do not represent best practice patient
care and suggested the department could consider if supporting person-centred, or wrap-around,
care approaches could be considered concurrently to the MSAC process. s47C
3
OFFICIAL: Sensitive
FOI 4876 - Document 19
s47C
The MSAC Executive agreed that it would not be feasible to undertake a HTA on each proposed
surgical item individually and therefore supported the HTA assessing the proposed surgical
MBS items as a suite. However, the MSAC Executive queried the department advice that the
consideration of amendments to consultation items should be considered and progressed
separately to the HTA on the surgical MBS items. The MSAC Executive reiterated their position
for a person-centred multidisciplinary team approach to be the focus of this application, not just
assessment of the surgical items.
The MSAC Executive considered that the appropriate HTA pathway to progress the application
would be a focussed HTA via the full MSAC pathway (i.e., consideration by PASC, ESC and
MSAC) that would collectively evaluate the suite of MBS items for gender affirming surgery. It
is anticipated the application would progress as a DCAR and would need to establish cost-
effectiveness of the comparator before progressing to assess comparative cost-effectiveness of
the intervention. The MSAC Executive agreed that there are some elements of the development
of the PICO that would benefit from PASC consideration before commencing a HTA such as
s47C
The MSAC Executive considered the assessment should be progressed as a two
UNDER CARE
stage Assessment Report pathway where the first stage would assess the comparative clinical
evidence and the second stage would look at the economic evaluation and
1982
financial analysis.
AGED
ACT AND
RELEASED
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
4
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Gender affirming care
CARE
o
Gender
UNDER
diverse people in Australia and
1982
AGED
New Zealand have overall poorer
ACT AND
heal
RELEASED
th outcomes when compared to
BEEN HEALTH cisgender people (1-4)
HAS INFORMATION
OF
OF
o
They report significantly higher levels
DOCUMENT
of psychological stress, suicidal
FREEDOM
DEPARTMENT
THIS THE
ideation and suicide attempts and have
THE
BY
poorer self-reported health than
cisgender people (1-4)
2
FOI 4876 - Document 20
Gender affirming care
o Currently in Australia and NZ gender diverse people report significant barriers to
accessing gender affirming treatment (1,4)
UNDER CARE
More than half of gender diverse peopl
1982 e report
AGED
that access to
ACT
gender affirming surgery in Australia
RELEASED is
AND a high priority (2)
BEEN HEALTH
19% of gender diverse people
HAS
i
OF n NZ report wanting but being
INFORMATION
unable to access hormonal
OF therapy (4)
DOCUMENT
DEPARTMENT
67% of trans men i FREEDOM
THIS n NZ report wanting, but being unable to
THE THE
access chest recons
BY truction surgery (4)
39-42% of gender diverse people in NZ reported wanting but
being unable to access orchidectomy or hysterectomy (4)
3
FOI 4876 - Document 20
Do gender affirming medical and s
UNDER CARE
urgical
1982
treatments work?
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Methods
o We searched Pubmed, Web of Science, Embase and Psych
UNDER CARE
Info in October 2022 using terms “transgend
1982
AGED
er”, “gender
affirming hormones”, “gender affirming
ACT
RELEASED AND surgery”, “quality of life”
BEEN HEALTH
HAS INFORMATION
OF
o Two independent researchers
OF individually conducted study
selection and critical apprais
DOCUMENT al us
DEPARTMENT ing PRISMA guidelines.
FREEDOM
THIS
THE THE
BY
Covidence
FOI 4876 - Document 20
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Inclusion criteria
✓ Studies in English
UNDER CARE
1982
AGED
✓ Published 2010 and later
ACT
RELEASED AND
✓
BEEN
Treatment with either surgery or hormo
HEALTH
nes for >3 months
HAS INFORMATION
OF
OF
✓ Studies using validated patient reported outcomes measures
DOCUMENT
FREEDOM
DEPARTMENT
of health-related quality
THIS of
THE
THE life or mental health
BY
FOI 4876 - Document 20
Exclusion criteria
X Non peer-reviewed studies
UNDER CARE
1982
AGED
ACT
X Reviews, editorials or case reports
RELEASED AND
BEEN HEALTH
X Treatment with puberty block
HAS ers
OF
INFORMATION
OF
X Dedicated paediatric studies
DOCUMENT
(<
DEPARTMENT 16 years)
FREEDOM
THIS
THE THE
BY
X Studies including <10 patients
8
FOI 4876 - Document 20
t
ar
ch
CARE
ow
UNDER
1982
AGED
fl
ACT
RELEASED AND
on
BEEN HEALTH
si
HAS INFORMATION
OF
OF
lu
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
y inc
BY
Stud
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Patient Reported Outcome Measures
o
Over 80 different PROM variations
UNDER CARE
o
Some very commonly used such as the SF36 and the WHO QOL
1982
AGED
questionnaire
ACT
RELEASED AND
o
Others only used a single time BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
Gender
Body Imag
THE
e/
THE
Mental
Health
BY
dysphoria
self- esteem
illness
related QOL
11
FOI 4876 - Document 20
Patient Reported Outcome Measures
The following questions ask about
how completely you experience or were able to do certain things in
the last two weeks.
UNDER CARE
1982 (Please circle the number)
AGED
ACT
WHO QOL questionnaire
RELEASED AND
Not at all
A little
Moderately
Mostly
Completely
BEEN HEALTH
HAS INFORMATION
OF
10. Do you have enough energy for everyday life?
OF 1
2
3
4
5
DOCUMENT
FREEDOM
DEPARTMENT
11. Are you able to accept your bodily appearance?
THIS THE
1
2
3
4
5
THE
BY
25. How satisfied are you with your mode of
1
2
3
4
5
transportation?
12
Gender Dysphoria
FOI 4876 - Document 20
o 9 prospective cohort studies, 6 with data for analysis
o 1 retrospective and 2 cross sectional studies were not included in analysis
Utrecht gender dysphoria scale
Disagree
UNDER CAREDisagree
Neither
Agree
Agree
completely
agree or
completely
1982
AGED
disagree
ACT
RELEASED AND
I prefer to behave like my affirmed gender.
1
2
3
4
5
BEEN HEALTH
Every time someone treats me like my assigned s
HAS ex, I
OF
1
2
3
4
5
INFORMATION
feel hurt.
OF
It feels good to live as my affirmed gender.
1
2
3
4
5
DOCUMENT
FREEDOM
DEPARTMENT
THIS
I always want to be treated like my affirm
THE ed
THE gender.
1
2
3
4
5
BY
A life in my affirmed gender is more attractive for me
1
2
3
4
5
than a life in my assigned sex.
I feel unhappy when I have to behave like my assigned
1
2
3
4
5
sex.
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Body Image and self-esteem
o 11 prospective cohort studies, 7 with data for analysis
o 3 retrospective, 7 cross sectional studies not included in analysis
UNDER CARE
1982
AGED
Self esteem scale: Rosenberg
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
15
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
Mental illness
FOI 4876 - Document 20
o 17 prospective cohort studies, 10 with data for analysis
o 5 retrospective, 15 cross sectional studies not included in analysis
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
17
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
Health Related quality of life
o 20 prospective cohort studies, 11 with data for analysis
o 11 retrospective, 17 cross sectional studies not included in analysis
UNDER CARE
1982 SF-36 Questionnaire
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
19
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 20
UNDER CARE
Conclusions
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
Gender affirming treatment in the form
HAS
OF
of
INFORMATION
hormone treatment
OF
and/or surgery results in significantly improved patient reported
DOCUMENT
quality of life, gender dysphorFREEDOM
DEPARTMENT
THIS
ia, body image, self esteem, anxiety,
THE THE
and depression in gender diver
BY
se people.
FOI 4876 - Document 20
References
1. Hill AO, Bourne A, McNair R, Carman M, Lyons A. Private Lives 3:The health and
wellbeing of LGBTIQ people in Australia. Melbourne, Australia: Australian Research
Centre in Sex, Health and Society, La Trobe Univeris
UNDER ty;
CARE 2020.
1982
AGED
2. Hyde Z, Doherty M, Tilley P, McCaul K, Rooney R, Jancey J. The First Australian
ACT AND
National Trans Mental health Study: Summary of
RELEASED Results Perth, Australia: School of
Public Health, Curtin University 2014. BEEN HEALTH
HAS INFORMATION
OF
3. Bretherton I, Thrower E, Zwickl S, Wong
OF
A, Chetcuti D, Grossmann M, et al. The
Health and Well-Being of Transgender Australians: A National Community Survey.
DOCUMENT
LGBT Health. 2021;8(1):42-9. FREEDOM
DEPARTMENT
THIS
THE THE
4. Veale J, Byrne J, Tan K, Guy S,
BY Yee A, Nopera T & Bentham R (2019)
Counting
Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New
Zealand. Transgender Health Research Lab, University of Waikato: Hamilton NZ.
22
FOI 4876 - Document 21
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
CARE
MSAC and its sub-committees.
UNDER
Sharing consultation input
1982
AGED
Submitted consultation input will be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant will receive a summary of comments from individuals, with th
AND e individual’s name and other
RELEASED
identifying information removed.
• MSAC and its sub-committees will receive both the summary and copies of the comments, with the name
of the individual and other identifying information re
BEEN moved.
HEALTH
• Consultation input from groups or organisations will be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA As
OF sessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS
THE THE
MSAC and its sub-committees consider consultation input when appraising an application, including to better
understand the potential impact
BY of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input will be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
Consultation deadlines. Please ensure that your consultation input is submitted by the pre-PASC or pre-MSAC
consultation deadline for this application. Consultation deadlines for each PASC and MSAC meeting are listed in
the PASC, ESC, MSAC key dates available on the MSAC website. They are also published in the MSAC Bulletin.
Consultation input received after the respective deadlines may not be considered.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email: xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1.
Respondent details
Name: Parents of Adolescents with Gender Distress - Victoria
Email: xxxx.xxx@xxxxx.xxx
Phone No:
2.
Is the feedback being provided on an individual basis or by a collective group?
Individual
Collective Group
If an individual, specify the name of the organisation you work for
If a collective group, specify the name of the group
CARE
Parents of Adolescents with Gender Distress - Victoria UNDER
1982
3.
How would you best identify yourself?
AGED
ACT
General Practitioner
RELEASED AND
Specialist
Researcher
BEEN
Consumer
HEALTH
Care giver
HAS INFORMATION
OF
Other
OF
If other, please specify
DOCUMENT
DEPARTMENT
A collective of families with ch
FREEDOM
ildren and young people affected by gender distress
THIS
THE THE
BY
2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
PART 2 – CLINICAL NEED AND PUBLIC HEALTH SIGNIFICANCE
4. Describe your experience with the medical condition (disease) and/or proposed intervention
and/or service relating to the application summary.
All of our children experience gender distress. Some have received ‘gender affirming care’ (GAC),
generally without appropriate psychosocial diagnosis and support. In our lived experience, GAC is
provided without a robust diagnostic process and co-occuring conditions of significance such as
eating disorders, mental illness and neurodiversity are not properly explored prior to GAC being
provided.
5. What do you see as the benefit(s) of the proposed medical service, in particular for the person
involved and/or their family and carers?
CARE
UNDER
1982
None.
AGED
ACT
6. What do you see as the disadvantage(s) of the proposed medical ser
AND
vice, in particular for the
RELEASED
person involved and/or their family and carers?
BEEN
HEALTH
HAS
OF
Easier and cheaper access to GAC under Medicare will result i
INFORMATION
n higher rates of surgery regret,
suicide and litigation as the evidence to support it is of low quality. Refer to attached letter.
OF
7. What other benefits can you see from having this intervention publically funded?
DOCUMENT
DEPARTMENT
FREEDOM
THIS THE
None.
THE
BY
8. What other services do you believe need to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
Comprehensive psychological evaluation and exploratory therapy by independent practitioners
MUST be delivered prior to GAC. This does NOT currently happen, so existing processes are
inadequate and not suitable for purpose.
3 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
PART 3 – INDICATION(S) FOR THE PROPOSED MEDICAL
SERVICE AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
A significant number of gender distressed young people are neurodiverse, suffer from
mental illness, body dysmorphia, eating disorders, chronic medical conditions. Any
population with these conditions should not be eligible without comprehensive and robust
psychological assessment and therapy, as recommended by RANZCP and NAPP
10. Have all the associated interventions been adequately captured in the application summary?
CARE
Yes
UNDER
No
1982
AGED
Please explain:
ACT
Appropriate psychological interventions that should be explore
AND
d prior to GAC have been
RELEASED
ignored in the application.
BEEN HEALTH
11. Do you agree or disagree that the comparator(s) to the proposed medical service?
HAS INFORMATION
OF
Strongly Agree
OF
Agree
Disagree
Strongly Disagree
DOCUMENT
Please explain:
FREEDOM
DEPARTMENT
THIS
Appropriate psychological interventions that should be explored prior to GAC have been
THE THE
ignored in the application.
BY
Comparing only to existing medical interventions ignores the increasing debate on
appropriate treatment for gender distress.
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
Statements and benefits made in the application are not supported by high quality
evidence, are contested within medical communities and are not supported by long term
research.
4 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
14.
Do you agree with the proposed service fee?
UNDER CARE
Strongly Agree
1982
Agree
AGED
Disagree
ACT AND
Strongly Disagree
RELEASED
Specify why or why not:
BEEN
HEALTH
Surgical treatments provided according to ‘patient choice’ without a diagnostic test are
HAS INFORMATION
OF
clearly elective and not clinically necessary. The service should not be funded by Medicare.
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
5 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
Gender distress is a highly controversial condition. Research quality is low, surgical
interventions are poorly evidenced and appropriate treatments are subject to
controversy.
Until sufficient medical consensus and long term research evidence is available, the
proposed medical service should not be funded by Medicare.
16. Do you have any comments on this feedback survey? Please provide comments or suggestions
on how this process could be improved.
CARE
UNDER
1982
Thanks you for the opportunity to participate. Please see attached letter for further detail.
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
Again, thank you for taking the time to provide valuable feedback.
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
6 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 21
Submission - 1754 - Patient consultations and surgical procedures for gender affirmation
in adults with gender incongruence
Our group PAGD VIC (Parents of Adolescents with Gender Distress, Victoria) are concerned
by Submission 1754 to extend Medicare coverage in Australia to those seeking 'gender
affirming' surgery. We are particularly concerned that statements made by Australian
Society of Plastic Surgeons (ASPS) in support of the application are based on low quality
data, are contested or simply incorrect. Specific statements of concern are below:
ASPS Submission Statements
PAGD Rebuttal
Conceptually it is important to understand that
These statements are made with no reference and
“gender incongruence” is the innate state.
are not consistent. There is no distinguishable
There are no prerequisite diagnostic tests required
clinical difference made between gender
to establish the presence of gender incongruence.
questioning and gender incongruence and no viable
Some individuals who are “gender questioning” will
explanation of why gender questioning may not be
not have gender incongruence, or it will not be
persistent but gender incongruence is innate.
persistent.
Surgery without an available test to establish a firm
clinical diagnosis cannot be medically necessary.
UNDER CARE
The number and type of gender affirming surgical
Surgery determined by patient choice rather than
procedures accessed by people will depend on their
medically diagnostic testing is clearly elective, not
1982
AGED
medical suitability for particular procedures, their
clinically necessary and therefore should not be
choices and whether they are pursuing
eligible for Medicare funding.
ACT AND
masculinising or feminising procedures
RELEASED
Eligibility for Medicare benefits being payable for
Eligibility is not established as without a diagnostic
gender affirming medical interventions rendered to
test, a GAC service cannot be determined to be
BEEN
people with gender incongruence is established by
clinically relevant.
HEALTH
The Health Insurance Act 1973, specifying that:
HAS
OF
GAC is NOT generally accepted in the medical
INFORMATION
A “clinically relevant service means a service
profession as being necessary as appropriate
OF
rendered by a medical practitioner that is generally
treatment for gender incongruence and is
accepted in the medical profession as being
increasingly contested. Both psychiatry peak bodies,
necessary for the appropriate treatment of the
RANZCP and NAPP contest the statement that GAC
patient to whom it is rendered”
DOCUMENT
is necessary or appropriate treatment.
DEPARTMENT
Gender affirming medical interventions hav
FREEDOM e been This statement is based on a low quality self
reported as reducing rates
THIS of psychological distress, reported survey. Higher quality longitudinal studies
THE
suicide ideation and suicide at
THE tempt.
have found that psychological distress, suicide
(Almazan et al. 2021).
BY
ideation and attempts increased significantly post
sex reassignment surgery.1
Standards of Care for the Health of Transgender and
The WPATH ‘Standards of Care’, Version 8 have
Gender Diverse People, Version 8 have been
been self described as such and do not meet the
endorsed as a Standard of Care by the Australian
requirements for clinical Standards of Care. Over
Professional Association for Trans Health (AusPATH)
2000 medical professionals, public health scientists
and other concerned individuals have signed a
declaration challenging the validity of the Standards
of Care.2
The Society estimates without justification ‘that 128,145 transgender Australian adults
would be candidates for gender-affirming medical interventions in 2023’. This represents
enormous growth in a remarkably short space of time and with a recognised lack of long-
term research on outcomes for these individuals3, significant regret is a very real possibility.
FOI 4876 - Document 21
Potential regret is hard to estimate but previous research data would suggest that outcomes
are not consistent with the benefits stated by the application. “The review of more than 100
international medical studies of post-operative transsexuals by the University of
Birmingham's aggressive research intelligence facility (Arif) found no robust scientific
evidence that gender reassignment surgery is clinically effective”4 “eight former patients of
the Gender Dysphoria Clinic at Melbourne's Monash Medical Centre believe they may have
been misdiagnosed. Some have tried to commit suicide while struggling to live as the
opposite sex after the irreversible operations”5
The Society suggests there is “broad public support” for its funding application. 148,000
signatures on a petition in a population of over 26,000,000 is disputed as “broad public
support” and we would question the relevance of ‘public support’ in determining the
medical recommendations for a specific treatment. We also challenge why a condition the
Society is seeking to de-pathologise requires such serious and ‘personal choice’ medical
interventions to be funded by tax payers.
PAGD would recommend that MSAC rejects this application based on the low quality of
evidence and current scientific uncertainty regarding gender dysphoria and t
CAREhe medical
UNDER
interventions being undertaken. We are happy to answer any questions you have regarding
1982
this submission.
AGED
ACT
Regards,
RELEASED AND
Parents of Adolescents with Gender Distress – Victoria
BEEN
xxxx.xxx@xxxxx.xxx
HEALTH
HAS INFORMATION
OF
1 “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in
OF
Sweden”.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885
2 https://beyondwpath.org/
3 “Psychiatry’s ethical involvement in gender-affirming care”.
DOCUMENT
https://journals.sagepub.com/doi/10.1177/1039856218775216
DEPARTMENT
4 “Sex changes are not effective, say researc
FREEDOM hers”
https://www.theguardian.co
THIS m/society/2004/jul/30/health.mentalhealth
THE
5 “Sex change clinic ‘got it wron
THE g’” https://www.smh.com.au/national/sexchange-clinic-got-it-wrong-
20090530-br3u.html
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 23
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
FOI 4876 - Document 23
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UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
3
FOI 4876 - Document 23
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
CARE
MSAC and its sub-committees.
UNDER
Sharing consultation input
1982
AGED
Submitted consultation input will be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant will receive a summary of comments from individuals, with th
AND e individual’s name and other
RELEASED
identifying information removed.
• MSAC and its sub-committees will receive both the summary and copies of the comments, with the name
of the individual and other identifying information re
BEEN moved.
HEALTH
• Consultation input from groups or organisations will be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA A
OF ssessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS
THE THE
MSAC and its sub-committees consider consultation input when appraising an application, including to better
understand the potential impac
BY t of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input will be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
Consultation deadlines. Please ensure that your consultation input is submitted by the pre-PASC or pre-MSAC
consultation deadline for this application. Consultation deadlines for each PASC and MSAC meeting are listed in
the PASC, ESC, MSAC key dates available on the MSAC website. They are also published in the MSAC Bulletin.
Consultation input received after the respective deadlines may not be considered.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email: xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1. Respondent details
Name:
Email:
@health.wa.gov.au
Phone No:
2. Is the feedback being provided on an individual basis or by a collective group?
Individual
Collective Group
If an individual, specify the name of the organisation you work for
WA Department of Health - North Metropolitan Health Service – Gender Pathways Service
If a collective group, specify the name of the group
CARE
UNDER
1982
3. How would you best identify yourself?
AGED
ACT
General Practitioner
RELEASED AND
Specialist
Researcher
BEEN
Consumer
HEALTH
Care giver
HAS INFORMATION
OF
Other
OF
If other, please specify
DOCUMENT
s47F
FREEDOM
DEPARTMENT
THIS THE
THE
BY
2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
PART 2 – CLINICAL NEED AND PUBLIC HEALTH SIGNIFICANCE
4. Describe your experience with the medical condition (disease) and/or proposed intervention
and/or service relating to the application summary.
I am a s47F
with experience in the assessment and support of people with Gender
Incongruence of Adolescence and Adulthood. I currently work as the s47F
in a
WA Department of Health service providing assessment of readiness for people seeking to access
gender affirming medical and/or surgical treatments, such as those proposed in the application.
5. What do you see as the benefit(s) of the proposed medical service, in particular for the person
involved and/or their family and carers?
The available literature, as cited in the application, demonstrates the psychological, emotional, and
social benefits of the proposed medical services. These medical services act to relieve or prevent
the gender dysphoria, which is associated with decreased qualify of life, increased suicidality, and
more severe mental health symptomatology.
UNDER CARE
6. What do you see as the disadvantage(s) of the proposed medical service, in particular for the
person involved and/or their family and carers?
1982
AGED
ACT
Nil
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
7. What other benefits can you see from having this intervention publicly funded?
These interventions are already accessed by those experiencing Gender Incongruence, with
DOCUMENT
payment typically comprising out of pocket fees or the use of other MBS items that are not specific
FREEDOM
DEPARTMENT
to the treatment of Gender Incongruence. The out-of-pocket fees place an unreasonable burden on
THIS
a client group who already face higher rates of socioeconomic disadvantage due to prejudicial and
THE THE
discriminatory public attitudes. Further, the use of other MBS items not specific to Gender
BY
Incongruence causes uncertainty or anxiety to health professionals providing a medically necessary
treatment with established efficacy.
8. What other services do you believe need to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
Some surgeons may request that the consumer consult with a Clinical Psychologist prior to the
proposed intervention and that the Clinical Psychologist provide documentation to the Surgeon
confirming the diagnosis of Gender Incongruence, and endorsing the consumers readiness for the
proposed intervention, including the capacity to provide informed consent. Currently, this service is
often funded using a GP Mental Health Care Plan and the associated MBS item numbers. Given that
Gender Incongruence is not a mental health disorder, this could potentially be seen as incorrect use
of such item numbers. The inclusion of Clinical Psychology or other mental health practitioner as
required by the Surgeon or requested by the consumer, in preparation for the intervention, should
3 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
also be considered with relevant MBS items. Some Surgeons may request that a Psychiatrist
provide this service, and I note such psychiatric input is already considered in the application
PART 3 – INDICATION(S) FOR THE PROPOSED MEDICAL
SERVICE AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
The proposed diagnosis of Gender Incongruence of Adolescence and Adulthood accurately
identifies the population for whom these services may be indicated.
The diagnostic criteria for Gender Incongruence of Adolescence and Adulthood, necessarily
and appropriately includes an element of self-determination, due to the inherently internal
nature of identity. However, the criterion of “persistent incongruence” is not well specified
and is interpreted differently across both professional background and between individual
clinicians. It may therefore be appropriate to provide more specific guidance to this
UNDER CARE
criterion as it relates to access to the proposed medical services. Developing guidance on
this criterion must be strongly guided by the views of those with live experience of gender
1982
incongruence. Further specificity of this criterion would provide greate
AGED
r certainty and
clarity for both clinicians forming this diagnosis, as well as for those individuals seeking to
ACT
access gender affirming medical and surgical care.
RELEASED AND
10. Have all the associated interventions been adequately captured in the application summary?
BEEN HEALTH
Yes
No
HAS INFORMATION
OF
Please explain:
OF
Whilst this field continues to evolve, the current range of gender affirming surgeries, to my
knowledge, is well captured in the application.
DOCUMENT
DEPARTMENT
FREEDOM
THIS THE
11. Do you agree or disag
THE
ree that the comparator(s) to the proposed medical service?
BY
Strongly Agree
Agree
Disagree
Strongly Disagree
Please explain:
The comparators accurately capture the medical interventions currently accessed for the
treatments of Gender Incongruence that are funded by out of pocket expenses or MBS
items not identified for gender affirmation currently.
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
Strongly Agree
4 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
Agree
Disagree
Strongly Disagree
Specify why or why not:
The evidence base for the proposed medical services is well established, as cited in the
application.
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
5 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
I am unable to comment as this is outside my area of knowledge.
14.
Do you agree with the proposed service fee?
UNDER CARE
Strongly Agree
1982
Agree
AGED
Disagree
ACT AND
Strongly Disagree
RELEASED
Specify why or why not:
BEEN
HEALTH
I am unable to comment as this is outside my area of knowledge.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
6 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 23
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
No
16. Do you have any comments on this feedback survey? Please provide comments or suggestions
on how this process could be improved.
No
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN
Again, thank you for taking the time to provide val
HEALTH
uable feedback.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
7 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
MSAC and its sub-committees.
UNDER CARE
Sharing consultation input
1982
AGED
Submitted consultation input wil be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant wil receive a summary of comments from individuals, with the i
AND ndividual’s name and other
identifying information removed.
RELEASED
• MSAC and its sub-committees wil receive both the summary and copies of the comments, with the name
of the individual and other identifying information rem
BEEN oved.
HEALTH
• Consultation input from groups or organisations wil be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA A
OF ssessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS THE
MSAC and its sub-committees c
THE onsider consultation input when appraising an application, including to better
understand the potential impac
BY t of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input wil be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
Consultation deadlines. Please ensure that your consultation input is submitted by the pre-PASC or pre-MSAC
consultation deadline for this application. Consultation deadlines for each PASC and MSAC meeting are listed in
the PASC, ESC, MSAC key dates available on the MSAC website. They are also published in the MSAC Bulletin.
Consultation input received after the respective deadlines may not be considered.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email: xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | Co n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1. Respondent details
Name:
Email:
@thorneharbour.org
Phone No:
2. Is the feedback being provided on an individual basis or by a col ective group?
Individual
Col ective Group
If an individual, specify the name of the organisation you work for
If a col ective group, specify the name of the group
Thorne Harbour Health (THH)
UNDER CARE
3. How would you best identify yourself?
1982
AGED
ACT
General Practitioner
RELEASED AND
Specialist
Researcher
BEEN
Consumer
HEALTH
Care giver
HAS INFORMATION
OF
Other
OF
If other, please specify
.
DOCUMENT
THH employs General Practitio
FREEDOM ners, Specia
DEPARTMENT lists and our Consumers are relevant to this
submission.
THIS
THE THE
BY
2 | Co n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
PART 2 – CLINICAL NEED AND PUBLIC HEALTH SIGNIFICANCE
4. Describe your experience with the medical condition (disease) and/or proposed intervention
and/or service relating to the application summary.
In 2016, Thorne Harbour Health (THH) established Equinox, a peer-led Trans and Gender Diverse
Health Service. We consult regularly with our patients to establish service needs and define priorities;
and our practice reflects the outcomes of these consultations. Equinox services include General
Practice healthcare, sexual health, mental health support, hormone initiation and management, pre-
exposure prophylaxis (PrEP) and vaccinations.
5. What do you see as the benefit(s) of the proposed medical service, in particular for the person
involved and/or their family and carers?
Medical interventions for gender affirmation is associated with improved health-related quality of life,
reduced psychological disorders after receiving medical interventions, reduced suicidal ideation and
suicide attempt, reduce gender dysphoria, and increased body satisfaction/image.
6. What do you see as the disadvantage(s) of the proposed medical service, in particular for the
person involved and/or their family and carers?
CARE
N/A
UNDER
1982
7. What other benefits can you see from having this intervention publicly fun
AGED
ded?
ACT
Beyond direct medical/wellbeing outcomes from gender affirmation surgery, there several social and
AND
financial benefits of the proposed medical service. At present, many t
RELEASED rans people access
superannuation to pay for surgery, which leaves them financial y worse off in the long-term. Trans
people often face social barriers to accessing high-income work (or any work at all). This results in
BEEN
significant negative long-term impacts on general health as trans p
HEALTH eople age with lower
superannuation and saving, and would likely i
HAS ncrease the
OF burden on the public health system more
broadly. Medical gender affirmation wil also contribute to addr
INFORMATION essing health inequities between trans
individuals and the general population.
OF
8. What other services do you believe need to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
DOCUMENT
DEPARTMENT
FREEDOM
PART 3 – INDIC
THIS
A
THE
TION
THE
(S) FOR THE PROPOSED MEDICAL
SERVICE
BY
AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
10. Have al the associated interventions been adequately captured in the application summary?
Yes
No
3 | Co n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
Please explain:
11. Do you agree or disagree that the comparator(s) to the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Please explain:
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
CARE
Specify why or why not:
UNDER
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
4 | C o n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
14.
Do you agree with the proposed service fee?
UNDER CARE
Strongly Agree
1982
Agree
AGED
Disagree
ACT AND
Strongly Disagree
RELEASED
Specify why or why not:
BEEN
HEALTH
HAS
OF
INFORMATION
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
5 | Co n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 24
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
16. Do you have any comments on this feedback survey? Please provide comments or suggestions
on how this process could be improved.
CARE
UNDER
1982
AGED
ACT
RELEASED AND
BEEN
Again, thank you for taking the time to provide v
HEALTH
aluable feedback.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
6 | Co n s u l t a t i o n S u r v e y o n t h e Ap p l i c a t i o n S u mma r y a n d P I CO S e t a n d / o r
P I CO Co n f i r ma t i o n
( Ne w a n d Ame n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
CARE
MSAC and its sub-committees.
UNDER
Sharing consultation input
1982
AGED
Submitted consultation input will be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant will receive a summary of comments from individuals, with th
AND e individual’s name and other
RELEASED
identifying information removed.
• MSAC and its sub-committees will receive both the summary and copies of the comments, with the name
of the individual and other identifying information re
BEEN moved.
HEALTH
• Consultation input from groups or organisations will be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA A
OF ssessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS
THE THE
MSAC and its sub-committees consider consultation input when appraising an application, including to better
understand the potential impac
BY t of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input will be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
Consultation deadlines. Please ensure that your consultation input is submitted by the pre-PASC or pre-MSAC
consultation deadline for this application. Consultation deadlines for each PASC and MSAC meeting are listed in
the PASC, ESC, MSAC key dates available on the MSAC website. They are also published in the MSAC Bulletin.
Consultation input received after the respective deadlines may not be considered.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email:
xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1. Respondent details
Name:
Email: s47F
Phone No:
2. Is the feedback being provided on an individual basis or by a collective group?
Individual
Collective Group
If an individual, specify the name of the organisation you work for
If a collective group, specify the name of the group
CARE
Genspect
UNDER
1982
3. How would you best identify yourself?
AGED
ACT
General Practitioner
RELEASED AND
Specialist
Researcher
BEEN
Consumer
HEALTH
Care giver
HAS INFORMATION
OF
Other
OF
If other, please specify
Genspect is an international alli
DOCUMENT ance of parent and professional groups whose aim is to
DEPARTMENT
advocate for a healthy approach to the care of gender non-conforming and questioning
FREEDOM
children and yo
THIS ung people. We number in our thousands, and our members include
THE
numerous clinician
THE s as well as medical researchers, teachers, parents and others concerned
with the wellbeing o
BY f gender questioning youth. Genspect wholeheartedly supports the
rights of sexual minorities in society and is proud to include gay, lesbian and transgender
members in our team, as well as detransitioners. We have a zero-tolerance policy towards
discrimination against sexual minorities.
2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
PART 2 – CLINICAL NEED AND PUBLIC HEALTH SIGNIFICANCE
4. Describe your experience with the medical condition (disease) and/or proposed intervention
and/or service relating to the application summary.
Genspect was formed to advocate for a non-medicalised approach to gender diversity, in light of the
large increase in children and young people presenting with gender dysphoria. Our members have
broad expertise relevant to the issue of gender incongruence/gender dysphoria, and include many
clinical professionals as well as transgender people, detransitioners, and parent groups. Through our
sister organisation Beyond Trans, we provide support for detransitioners. In addition, we provide
support and information for parents of children with gender dysphoria.
We are of the strong opinion that young adults and children are not equipped to make decisions
about life-long changes associated with medical transition procedures. Adolescence and young
adulthood are key developmental stages during which a sense of identity evolves. We believe that
young people should be supported to accept and embrace their bodies in order to be healthy and
content. We do, however, support the rights of mature adults, who possess capacity, to make
informed healthcare choices regarding medical transition. Our experience is that young adults are
currently making decisions on gender transition that many of them come to regret. In November
2023, Genspect will launch our Gender Framework document, which outlines a non-medicalised
CARE
pathway for the management of gender dysphoria.
UNDER
1982
5. What do you see as the benefit(s) of the proposed medical service, in particular for the person
AGED
involved and/or their family and carers?
ACT AND
We do not see benefits for these services for the vast majority of th
RELEASED ose currently requesting them,
who will instead suffer damage.
BEEN
The bulk of those requesting these treatments are a new cohort of adolescents and young people, the
HEALTH
majority female, as discussed in section 9 [1]. The rapid upswing in these people identifying as gender
HAS
OF
incongruent has characteristics of social contagion and parallels
INFORMATION the rise of smart phone and social
media use. Many of these young people present with a keen desire for hormones and surgery to alter
OF
their outward appearance. The strong ideological commitment of this new cohort to transgender
issues and their intense desire for treatment means that there is certainly a “honeymoon” period
when they get what they have been seeking. The studies that report decreased depression or suicidal
DOCUMENT
ideation in patients who have received treatment are generally looking at relatively short-term
DEPARTMENT
outcomes. This may well be a placebo ef
FREEDOM fect, rather than true therapeutic benefit [2]. However, the
long-term outcomes of t
THIS his treatment, particularly for this cohort, are completely unknown [3]; there
THE
are increasing numbers of d
THE etransitioners emerging who equally keenly regret their treatment. Please
see section 9 for further discu
BY ssion of this.
1. Kaltiala, R., Bergman, H., Carmichael, P., de Graaf, N. M., Egebjerg Rischel, K., Frisén, L., Schorkopf,
M., Suomalainen, L., & Waehre, A. (2020). Time trends in referrals to child and adolescent gender
identity services: A study in four Nordic countries and in the UK. Nordic Journal of Psychiatry,
74(1), 40–44. https://doi.org/10.1080/08039488.2019.1667429
2. Clayton, 2023. Gender-affirming treatment of gender dysphoria in youth: A perfect storm
environment for the placebo effect – The implications for research and clinical practice. Archives
Sex Behav. 52:483-494. Doi: 10.1007/s10508-022-02472-8
3. Levine, S. B., Abbruzzese, E., & Mason, J. M. (2022). Reconsidering informed consent for trans-
identified children, adolescents, and young adults. Journal of Sex & Marital Therapy, 48(7), 706–
727. https://doi.org/10.1080/0092623X.2022.204622)
3 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
6. What do you see as the disadvantage(s) of the proposed medical service, in particular for the
person involved and/or their family and carers?
1. The possibility of future regret. The true rate of regret for transgender treatment and surgery is
completely unknown, for several reasons [4]. Firstly, the poor quality of the published data and very
high loss to follow-up in studies, as detailed in section 12. Secondly, the nature of the population
seeking these services has now changed due to a massive increase in identification of adolescents and
young people as gender incongruent, particularly girls and young women. (See below). The rate of
regret or detransition in this population remains to be determined as it is a new phenomenon.
However, one paper analysing data on hormone prescriptions in US military families found that the 4-
year discontinuation rate for hormone prescriptions was 30% overall and 36% for transmasculine [5].
The existence of detransitioners who were formerly convinced that they were transgender
contradicts the concept expressed in the application that gender incongruence is an “innate state”.
Thus, we can anticipate that surgery amongst this new cohort with cross-sex identification initiating in
adolescence will result in large numbers of regretful patients.
2. High rate of complications and poor outcomes for some of these surgeries. As cited in the
application, a review on phalloplasty found complications reported for 54% of patients although as it
was noted that many articles did not comment on complications, this number can be assumed to be a
minimum [6]. This should not be acceptable in elective surgery, and revision surgeries will significantly
add cost burden. A review on surgeries generating a neo-vagina found that “studies reported on 1,684
patients with an overall complication rate of 32.5% and a reoperation rate of 21.7% for non-esthetic
reasons” [7]. Another study found that “common patient-reported symptoms during clinical visit
UNDER CARE
included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual
function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%)
1982
being the most frequent [8].
Construction of a neo-vagina using intestinal segme
AGED nt is a risky
procedure used when there is insufficient penile tissue due to prior treatment with puberty blocking
ACT
drugs. This operation led to the death of an 18 year old from an
E. coli in
AND fection that was likely
RELEASED
introduced with the colonic tissue [9]. Even double mastectomy has an unacceptable risk profile for
an elective surgery where the aim is purely for an aesthetic outcome. One published case study
details the outcome for a regretful Australian patient
BEEN who had a double mastectomy at 20 years old:
HEALTH
“The surgical outcome was not what was expected. There was extensive hypertrophic scarring,
particularly around and under the nipple graf
HAS ts, which w
OF ere painful and itchy to the extent that
INFORMATION
wearing clothing was uncomfortable.
s22
OF
The subject also details that her
transgender friends also discouraged he
DOCUMENT r from speaking about this because “you are making trans
surgery look bad.” This emphasises the ideological h
DEPARTMENT old which is preventing proper analysis of
FREEDOM
outcomes.
THIS
3. Long term loss of bodily function
THE
and health. Published work
generally only details immediate
THE
surgical complications, and not the long-term health consequences for patients. We frequently only
BY
hear of these through online accounts of those who have undergone the procedures. Chronic urinary
tract infections, incontinence, and other urinary problems appear to be common long-term
consequences of genital surgery. One detransitioner who has undergone vaginoplasty has written
about the outcome – s22
. It is beyond the scope of what we can cover here, but of
course there are also multiple long term and poorly understood health consequences of cross-sex
hormones, for example on cardiovascular health, vaginal and uterine atrophy, etc.
4. Loss of fertility. This is evident for those undergoing surgeries removing gonads, but potentially
also a result of long-term hormonal treatment.
5. Loss of ability to breast feed. The regret of many detransitioners at loss of ability to breastfeed is
frequently noted in their public statements, and has been published for the Australian detransitioner
mentioned above - “It was really hard knowing that he wanted to breastfeed, and I couldn’t give him
that….And when they put him on my stomach, he crawled up, he was looking for my breasts….he
spent so much time in his early life trying to fine my breasts.” [10].
4 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
6. Loss of sexual function. Internet chat rooms for transgender individuals reveal many concerns of
former patients about sexual function. A well-known detransitioner several years post-vaginoplasty
has written on Twitter: s22
]. The problem of narrow and shallow neo vagina is frequently commented on – this
new orifice is permanently trying to heal, and has to be maintained by frequent, sometimes daily
painful “dilation” sessions. Even with these efforts, depth and width are not always maintained.
Outcomes for sensation are also unreliable. For females, vaginal atrophy from testosterone use is a
substantial problem in maintaining sexual activity [12].
7. Difficulty forming relationships. A mature and thoughtful transsexual,
, who
recognises that her transition 30 years ago was a response to internalised homophobia, has written
eloquently about the difficulty in finding a life partner: s22
8. Lack of mental health benefit. Although it is an oft-repeated mantra that these treatments are
“life-saving”, there is no good quality evidence for that, and the problems in the literatu
CARE re are
UNDER
detailed in section 12. A recent study on the Danish population of more than 6 million shows that
suicide attempts and mortality remain high in adult transgender population
1982 s [14]. Preliminary data
AGED
from Finland reported at a conference showed that gender reassignment treatment did not affect the
need for ongoing psychiatric treatment [15]. There is no good qualit
ACT y research to indicate that
AND
surgical treatments improve mental health outcomes or lessen the r
RELEASED isk of suicide. One study noted
“the level of life satisfaction in transgender people was not increased in transgender who had
undergone gender-affirming surgery as compared to those who were unoperated. A possible
BEEN
explanation may be that gender-affirming surgery – similar to othe
HEALTH r critical life events—only had a
short-term effect on life satisfaction and bounces back to the initial set point of life satisfaction after
HAS
OF
some years.” [16]
INFORMATION
9. Impact on family. Our organisation fields daily enquiries from confused and grieving families. Many
OF
are torn apart by this issue. The majority are parents of children or young adults in the new
adolescent-onset group. They can detail the multiple psychiatric co-morbidities or traumas that have
led to this identification, and the majority say there was no early life gender non-conformity. This
DOCUMENT
contradicts the idea presented in this application that this clinical diagnosis of gender incongruence is
DEPARTMENT
somehow “innate’. Parents universally a
FREEDOM cknowledge the impact of online material and social media.
THIS
They are frequently manipulated by clinicians who tell them that their child is likely to commit suicide
THE THE
if they do not medically transition gender. Families are highly distraught at seeing their children
BY
undertake medical treatment that they believe will cause long-term harm, with the mental health toll
on parents continuing for many years.
4. Cohn, 2023. The detransition rate is unknown. Arch Sex Behav. 52:1937-1952
https://doi.org/10.1007/s10508-023-02623-5
5. Roberts et al, 2022. Continuation of gender-affirming hormones among transgender adolescents and adults. J
Clin Endocrinol Metab. 107:e3937-e3943. https://doi.org/10.1007/s10508-023-02623-5
6. Morrison 2016 Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg. 2016 138(3):594-
615. doi: 10.1097/PRS.0000000000002518.
7. Cutruzzula Dreher, 2017. Complications of the neovagina in male-to-female transgender surgery: A
systematic review and meta-analysis with discussion of management. Clinical Anatomy 31:191-199.
https://onlinelibrary.wiley.com/doi/abs/10.1002/ca.23001t.
8. Potter, 2023. Patient reported symptoms and adverse outcomes seen in Canada’s first vaginoplasty
postoperative care clinic. Neurourol Urodyn 42:523-529. doi: 10.1002/nau.25132.
5 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
9. Negenborn, 2017. Lethal necrotizing cellulitis caused by ESBL-producing E. coli after latharoscopic intestinal
vaginoplasty. J Pediatr Adolesc Gynecol 30:e19-e21. https://doi.org/10.1016/j.jpag.2016.09.005
10. Gribble et al, 2023. Breastfeeding grief after chest masuculinisation mastectomy and detransition: A case
report with lessons about unanticipated harm. Front Global Women’s Health 4:1073053. Doi:
10.3389/fgwh.2023.1073053.
s22
14. Erlangsen, 2023 Transgender identity and suicide attempts and mortality in Denmark. JAMA 329:2145-2153.
https://doi.org/10.1001/jama.2023.8627
15. https://benryan.substack.com/p/youth-gender-transition-treatment
16. Grupp, 2023 Are transgender people satisfied with their lives? BMC Public Health 23:1002.
DOIhttps://doi.org/10.1186/s12889-023-15831-4
CARE
UNDER
1982
7. What other benefits can you see from having this intervention publicly fun
AGED
ded?
ACT
None. The funding of these interventions would amount to public funding for elective cosmetic
AND
surgery, given that the sole requirement is the very loose diagnosis
RELEASED of gender incongruence. These
treatments are not medically necessary, and there is no requirement for a psychiatric assessment
under this application. The surgeries are likely to lead to long term health consequences. Public
BEEN
funding for these procedures cannot be justified on medical or econ
HEALTH omic grounds.
HAS INFORMATION
OF
8. What other services do you believe need to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
OF
People presenting with gender incongruence require appropriate long-term psychological therapy
that takes a neutral rather than affirmative approach, before any medical intervention is
DOCUMENT
contemplated. Common underlying co-morbidities and potential reasons for the feeling of gender
DEPARTMENT
incongruence should be explored, such a
FREEDOM s internalised homophobia, autism, ADHD, obsessive
compulsive disorder, early
THIS -life bullying, sexual assault and other trauma, family relationship
THE
breakdowns. There should
THE also be a requirement for an extensive period of social transition of several
years duration, before any me
BY dical treatment.
PART 3 – INDICATION(S) FOR THE PROPOSED MEDICAL
SERVICE AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
The proposed population is “individuals experiencing gender incongruence and electing to
pursue medical interventions as part of their gender affirmation process” with the diagnosis
being according to the WHO ICD-11 HA60 for Gender Incongruence of Adolescence and
6 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
Adulthood. There is very poor justification given for this population to be offered Medicare-
listed treatments, as detailed below.
1. Lack of any meaningful diagnostic criteria. The diagnosis according to the WHO ICD-11
HA60 relies on just “marked and persistent incongruence between an individual´s
experienced gender and the assigned sex”. So, all that is relied upon is the patient’s assertion
of their feelings, and adherence to gender stereotypes that are to a great extent socially
constructed. The application suggests that “the length of time of what constitutes
‘persistent’ gender incongruence is self-determined by the patient.” (page 4), and thus the
clinician seems to have little role in the diagnosis. Furthermore, the diagnosis of gender
incongruence relies heavily on the patient’s belief in rigid gender stereotypes. A patient will
only sense a mind-body mismatch if they have restrictive ideas about the behaviour of each
sex. A liberating broadening of outlook, rather than changing the body would seem to be a
healthier option.
2. Unprecedented rise in numbers of adolescents and young people identifying as “gender
incongruent”. In the past decade there have been rapidly escalating numbers of children and
young people with gender associated distress across the western world [17]. This is also
documented in Australia; although there are no figures available for the increase in adult
presentations, children’s gender clinics have recorded a dramatic increase in some states
[18] (Figure 1). Early figures from the Royal Children’s Hospital in Melbourne showed that
new cases referred for gender issues were 0-2 per year prior to 2009, followed
CARE by 8 in 2011
UNDER
and relentlessly increasing since then to more than 1000 in 2022 [18,19]. Transgender
support groups assert that this increase reflects increased accepta
1982 nce of transgenderism,
AGED
and hence people being more comfortable to now “come out”. If, as suggested, this gender
incongruence is “innate” we would expect to see similar pro
ACT portions emerging in all age
AND
groups, but there is no evidence for a similar rate of increas
RELEASED e for those over 30. Anecdotally,
what we instead see is a lot of middle-aged women saying that they are glad this
phenomenon did not exist when they were young, because as teenagers they would have
BEEN
readily opted out of womanhood and done permanent damage
HEALTH
to their bodies and fertility.
The increase is driven by teens and early twenties, predominantly female, who are the
HAS
OF
cohort historically most susceptible to social contagion
INFORMATION . However, there are many factors
that are likely contributing.
OF
Figure 1. Australian figures for new enrolments each year at the major children’s gender
clinic in each state [18]. This is based on data provided by the gender clinics under GIPPA
DOCUMENT
(formerly FOI). Note that the figures do not include Maple Leaf House in Newcastle (NSW) or
DEPARTMENT
any private treatments.
FREEDOM
THIS
THE THE
BY
7 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
3. Comorbidities and alternative explanations for presentation. Those presenting with
gender incongruence have a high rate of mental health co-morbidities or other features of
their background that may explain the presentation, rather than it being “innate”. High rates
of autism, ADHD and other conditions such as obsessive compulsive disorder are seen in
presenting individuals. As a result of neurodivergent features, the patients frequently feel
like outsiders and seek an explanation for why they feel different. There are high rates of
self-harm, eating disorders, experiences of trauma such as sexual assault, family breakdown,
and disproportionate numbers of children in out-of-home care. The latter point alone
indicates that gender incongruence can be trauma-related rather than innate. Many patients
are same-sex attracted, and failing to accept that. Consequently, gender transition for these
people can be viewed as regressive conversion therapy.
4. Increasing numbers of detransitioners and legal action against clinicians. As noted in
section 6, the true rate of regret and detransition is not known. What is clear is that
transgender activists viciously attack public detransitioners, and thus few are prepared to
speak openly. However, there are more than 50,000 members of the online detransitioner
support group on Reddit, r/detrans. These people document a myriad of health complaints
that they attribute to hormones and/or surgery, apart from their distress at their altered
appearance. Our experience shows that regret often takes 7-10 years, and numbers entering
clinics are still increasing; hence, we can expect the needs of detransitioners to be an
escalating concern. There is mounting anger amongst detransitioners about the
CARE medical
UNDER
treatment that was promoted to them as the best option to resolve their distress. There are
increasing numbers of legal cases being mounted for medical malp
1982 ractice. We have
AGED
documented 16 ongoing court cases, with three new cases in the US emerging in the past
week. There is at least one legal case mounted in Australia,
ACT by a young woman who was
AND
rushed through hormone treatment, mastectomy and hystere
RELEASED ctomy. [20]
5. Poor justification for treatment. WHO has redefined gender identity related health issues
BEEN
in the ICD-11, moving them from the “mental and behaviou
HEALTH ral disorders” chapter to the
“conditions related to sexual health”. There has been a concerted move to destigmatise and
HAS
OF
depathologise the condition, arising not from improve
INFORMATION d medical understanding, but as the
result of intense lobbying by transgender activists. And this continues, as groups still consider
OF
the term “gender incongruence” to be pathologizing [21]. Distress associated with the
condition is not a requirement for treatment under this proposal. It should then be asked, if
this is not a pathology and there is no need for distress, what is the purpose of the radical
DOCUMENT
surgical procedures, and how are they medically justified? The application notes that “The
DEPARTMENT
medical interventions accessed
FREEDOM will depend on a person’s personal choice as to which
THIS
medical affirmation intervention(s) are right for them.” This further emphasises that these
THE THE
are considered elective cosmetic surgeries, performed at the whim of the patient. Medical
BY
treatments should be recommended by clinicians following to a process of careful
assessment and diagnosis and according to the medical evidence, not just selected by
patients.
6. There are no restrictions sought. The application states that individuals diagnosed as
above would be eligible for the medical interventions, with no restrictions requested. There
is therefore no consideration of the person’s mental health status at the time that they seek
radical surgery. It is well acknowledged that the population with gender incongruence has a
high burden of mental health co-morbidities, and it is inconceivable that this is not taken into
account when considering suitability for surgery. Under these conditions, there will be a
large burden of patients regretting surgery.
7. No good quality evidence for improvement in mental health The application asserts that “gender affirming” medical interventions have been reported as
reducing rates of psychological distress, suicide ideation and suicide attempts. The cited
reference [22] is based on a low quality online survey. This survey was restricted to those
over 18 who identified as transgender, but had an unusual number of people claiming to be
8 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
18, suggesting the participation of many children. The ideological nature of this issue makes
online surveys the least reliable source of data. In addition, people who have detransitioned
or desisted would not have taken the survey. Similar problems of low quality data beset most
of the research literature claiming benefit for gender interventions.
No studies have
examined whether mastectomies, vaginoplasties or phalloplasties are superior to
psychological suicide prevention support. 8. Current effects of loose diagnostic criteria. Most Australians would expect that since
medical gender transition is a very serious, invasive, and potentially medically damaging
procedure, it would only be undertaken by individuals who are truly tormented by a
perceived mismatch between body and mind, and for whom all other approaches have
failed. The truth of medical practice in this field currently in Australia is far from that. In
practice, for both child and adult gender-related medicine, diagnosis is predominantly
patient-led. As long as an “appropriate” practitioner is selected, treatment is solely
dependent on what outcome the patient desires. For adults, hormones are freely available
from particular GP clinics under “informed consent” with no requirement for psychological or
psychiatric involvement. This generally involves two appointments; one where the patient is
interviewed on their health status and desired treatment, and a blood test taken for baseline
hormone levels, and a second appointment for prescription. Perusing online chat support
groups shows that this is commonplace in Australia, with people seeking advice on where to
get hormones or surgery with minimal “gatekeeping”. Similarly, in this application, diagnosis
of gender incongruence is proposed to be by a general practitioner with no req
CARE uirement for
UNDER
distress. This is a very low bar for permanent, life-altering and radical surgery that is not
medically necessary.
1982
AGED
17. Kaltiala, R (2020). Time trends in referrals to child and adolesc
ACT ent gender identity services: A study
AND
in four Nordic countries and in the UK. Nordic Journal of Psychiatry, 74(1), 40–44.
RELEASED
https://doi.org/10.1080/08039488.2019.1667429
18. Kenny, D.T. (2022) Number of children enrolled, receiving puberty blockade and cross sex hormones
in five gender clinics in Australia, 2014-2021.
BEEN https://diannakenny.com.au/number-of-children-
HEALTH
enrolled-receiving-puberty-blockade-and-cross-sex-hormones-in-five-gender-clinics-in-australia-
2014-2021/ Additional data for 2022 obtained by personal communication with D. Kenny.
HAS INFORMATION
OF
19. Tomazin, 2020. Staying on her feet: how Michelle Telfer won the gender clinic battle. The Sydney
Morning Herald. 2020-04-18 https://www.smh.com.au/lifestyle/health-and-wellness/staying-on-
OF
her-feet-how-michelle-telfer-won-gender-clinic-battle-20200416-p54kjf.html
20. Szego, 2022. ‘Absolutely devastating’: woman sues psychiatrist over gender transition. Sydney
Morning Herald. 2022-08-24 https://www.smh.com.au/national/absolutely-devastating-woman-
sues-psychiatrist-over-gender-
DOCUMENT transition-20220823-p5bbyr.html
21. https://tgeu.org/icd-11-depathologizes-tran
DEPARTMENT s-and-gender-diverse-identities/
FREEDOM
22. Almazan, 2021. Association between gender-affirming surgery and mental health outcomes. JAMA
THIS
Surgery 156:611-618.
THE THE
BY
10. Have all the associated interventions been adequately captured in the application summary?
Yes
No
Please explain:
Need for reversal surgeries. If these surgeries are permitted then there will be an increasing
burden of people with regret, who want the surgeries reversed. These people would not be
able to receive any support under this plan, as they will not be then diagnosed with gender
incongruence. There will be males wanting breast implants removed and females wanting
breast reconstructive surgery. In the more challenging situation of regret of genital
reassignment surgery by male patients, one paper reports performing reconstructive surgery
for seven patients, using a three step procedure: “removal of female genitalia with
9 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
scrotoplasty and urethral lengthening, total phalloplasty with microvascular transfer of a
musculocutaneous latissimus dorsi flap, and neophallus urethroplasty with penile prosthesis
implantation.” [23]. If the medical system is going to create problems, it should take
responsibility for repairing the damage.
Patients who regret the surgeries proposed in this application will have suffered iatrogenic
harm, and should be supported and compensated
23. Djordjevic et al. 2016 Reversal surgery in regretful male-to-female transsexuals after sex
reassignment surgery. J Sex Med 13:1000-1007.
11. Do you agree or disagree that the comparator(s) to the proposed medical service?
Strongly Agree
Agree
Disagree
Strongly Disagree
Please explain:
This application does not consider the alternative approach of psychological therapy to
explore the reasons behind gender incongruence and to help the person become
CARE
UNDER
comfortable in their own body. This is a much healthier and less damaging approach in the
long term, and requires us to question the application’s unsubstantiated claim that the
1982
AGED
gender incongruence as currently (but not previously) experienced in large numbers of
adolescents is “innate”.
ACT AND
RELEASED
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
BEEN HEALTH
Strongly Agree
HAS
OF
Agree
INFORMATION
Disagree
OF
Strongly Disagree
Specify why or why not:
DOCUMENT
The claim is made that the health outcomes under this application will be non-inferior to
FREEDOM
DEPARTMENT
doing the same procedures without specific Medicare item numbers. This is a trivial and
THIS
meaningless comparison, due to use of the wrong comparator. It would be more appropriate
THE THE
to ask whether health outcomes would be better than (i) doing no treatment, or (ii) providing
BY
appropriate psychological therapy. There is no research, that makes these necessary
comparisons.
There is a large discrepancy between published claims of benefits for these surgeries and the
reality for those receiving them. The contact that our organisation has with those who regret
their surgical treatments, as well as the online chat groups, tell a quite different story from
the clinical literature. The medical literature in this field is failing to accurately report
outcomes, or do the necessary comparisons, due to the following issues:
1. Bias and conflict of interest. The majority of clinicians publishing on these treatments are
those providing the treatments. It is inappropriate that the only published records are from
those making money from the treatments. This clear conflict of interest is generally
unacknowledged. There is a heavy bias towards presenting the outcomes of their work in the
best light. Researchers who are not connected with the treatment, and are therefore less
likely to be biased, cannot readily access this patient group.
2. Inadequate length of follow-up. Many studies are only reporting short-term outcomes.
Our experience is that regret often takes 7-10 years.
1 0 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
3. Loss to follow-up. Published studies frequently have 30-40% loss to follow-up. These may
include cases of regret and detransition, those who wish to have no further contact with
gender services, as well as suicide.
4. Limited studies on the new cohort of adolescent-onset gender dysphoria. Many of the
studies are still reporting on an earlier cohort of people seeking gender transition – often
those who were mature men at the time of transition. In addition, when this process was
much less common, patients went through much more extensive psychiatric assessment. The
rates of regret for these patients of previous years will not be relevant now to the large
numbers of adolescents who seek gender treatments with minimal psychological or
psychiatric assessment.
5. Asking the wrong questions. Patients may be asked if they regret the treatment. These
treatments, that may include loss of genitals or breasts, are drastic interventions. Admitting
regret for this may be very hard to do, and patients may find that they have to really
convince themselves that everything is OK, in order to maintain stability. Asking more
nuanced questions may elicit more revealing answers. In many published studies, patient
interviews are not done, and the assessment purely relies on medical records, and whether
regret or attempts to reverse the surgery were recorded in the patient’s clinical file. These
are not stringent assessments.
A number of recent papers have addressed the lack of good quality of evidence supporting
both child and youth gender transition [24-28].
UNDER CARE
This is a highly politicised area of medical practice. It is essential that a truly independent
review of evidence is done before any decision is taken to include t
1982 he proposed treatments
AGED
as part of the MBS. There are vested interests who stand to profit, including plastic surgeons,
and also a strong ideological push for these treatments from a
ACT ctivists, some of whom are
AND
clinicians. These interests should not be allowed to dominat
RELEASED e, and a fair assessment of the
clinical evidence must be completed.
BEEN
24. Abbruzzese, 2023. The myth of “reliable research” in pediatric gender medicine: A critical
HEALTH
evaluation of the Dutch studies and research that has followed. J Sex Marital Ther 49: 673-699. Doi:
HAS
OF
10.1080/0092623X.2022.2150346 INFORMATION
25. Clayton, 2022. The gender affirmati
OF ve treatment model for youth with gender dysphoria: A medical
advance or dangerous medicine? Arch Sex Behav 51: 691-698. Doi:
10.1080/0092623X.2022.2150346
DOCUMENT
26. Levine, 2023. Current concerns about gender-affirming therapy in adolescents. Curr Sex Health Rep
FREEDOM
DEPARTMENT
15: 113-123. Doi: 10.1080/0092623X.2022.2150346
THIS
THE
27. Levine, 2022. Re
THE considering informed consent for trans-identified children, adolescents and young
adults. J Sex Mari
BY tal Ther 48:706-727. Doi: 10.1080/0092623X.2022.2046221
28. Biggs, 2023 The Dutch protocol for juvenile transsexuals: origins and evidence. J Sex Marital Ther
49: 348-368. Doi: 10.1080/0092623X.2022.2150346
1 1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
Strongly Agree
Agree
Disagree
Strongly Disagree
Specify why or why not:
The suggested surgeries should not be listed on the MBS.
The application makes clear that the proposed surgical treatments are elective cosmetic
surgeries as they seek to achieve a patient-defined aesthetic outcome, lack adequate
evidence for improvement of patient health, and on the contrary will always worsen physical
health by destroying healthy and functional breasts or genitals.
14.
Do you agree with the proposed service fee?
UNDER CARE
Strongly Agree
1982
Agree
AGED
Disagree
ACT AND
Strongly Disagree
RELEASED
Specify why or why not:
BEEN
HEALTH
The procedures should be classified as cosmetic and not attract a medicare service fee.
HAS INFORMATION
OF
The application makes clear that the proposed surgical treatments are elective cosmetic
surgeries as they seek to achieve a patient-defined aesthetic outcome, lack adequate
OF
evidence for improvement of patient health, and on the contrary will always worsen physical
health by destroying healthy and functional breasts or genitals.
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
1 2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 25
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
The proposed interventions risk long-term health complications that affect not only the individual but
also Australia’s health budget.
16. Do you have any comments on this feedback survey? Please provide comments or suggestions
on how this process could be improved.
CARE
UNDER
1982
AGED
ACT
RELEASED AND
BEEN HEALTH
Again, thank you for taking the time to provide valuable feedback.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
1 3 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
Consultation Survey on
MSAC Application 1754
Patient consultations and surgical procedures for gender
affirmation in adults with gender incongruence
MSAC welcomes input on MSAC applications for public funding from individuals, organisations representing
health professionals or consumers and/or carers, and from other stakeholders. Please use this template to
prepare your input. You may also attach additional information if you consider it may be useful in informing
CARE
MSAC and its sub-committees.
UNDER
Sharing consultation input
1982
AGED
Submitted consultation input will be routinely
shared with the applicant and with MSAC and its sub-committees.
ACT
• The applicant will receive a summary of comments from individuals, with th
AND e individual’s name and other
RELEASED
identifying information removed.
• MSAC and its sub-committees will receive both the summary and copies of the comments, with the name
of the individual and other identifying information re
BEEN moved.
HEALTH
• Consultation input from groups or organisations will be provided in a complete form to both the applicant
HAS
OF
and to MSAC and its sub-committees.
INFORMATION
Consultation input may also be shared with HTA A
OF ssessment Groups from time to time to inform their reports to
MSAC or with state and territory health representatives where the application is for a service to be delivered
through public hospitals. Please do not include information in your input that you do not want shared as outlined
above. In addition, to protect privacy, do not include identifying personal (e.g., name) or sensitive (e.g., medical
DOCUMENT
history) information about third parties, such as medical professionals or friends/relatives.
FREEDOM
DEPARTMENT
How consultation input is used
THIS
THE THE
MSAC and its sub-committees consider consultation input when appraising an application, including to better
understand the potential impac
BY t of the proposed medical technology/service on consumers, carers, and health
professionals. A summary of consultation input will be included in the Public Summary Document (PSD)
published on the MSAC website once MSAC has completed its appraisal. The PSD may also cite input from
groups/organisations, including the name of the organisation. As such, organisations should not include
information or opinions in their consultation input that they would not wish to see in the public domain.
For further information on the MSAC consultation process please refer to the MSAC Website or contact the
Consumer Evidence and Engagement Unit on email: xxxxxxxxxxxx@xxxxxx.xxx.xx.
Thank you for taking the time to provide consultation input. Please return your completed survey to:
Email:
xxxxxxxxxxxx@xxxxxx.xxx.xx
Mail:
MSAC Secretariat,
MDP 960, GPO Box 9848,
ACT 2601.
1 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
PART 1 – PERSONAL AND ORGANISATIONAL INFORMATION
1. Respondent details
Name: Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Email: xxxxxxxx@xxxxxxx.xxx.xx
Phone No:
2. Is the feedback being provided on an individual basis or by a collective group?
Individual
Collective Group
If an individual, specify the name of the organisation you work for
If a collective group, specify the name of the group
CARE
Royal Australian and New Zealand College of Obstetricians and Gynaecologis
UNDER ts
1982
3. How would you best identify yourself?
AGED
ACT
General Practitioner
RELEASED AND
Specialist
Researcher
BEEN
Consumer
HEALTH
Care giver
HAS INFORMATION
OF
Other
OF
If other, please specify
DOCUMENT
FREEDOM
DEPARTMENT
THIS THE
THE
BY
2 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
PART 2 – CLINICAL NEED AND PUBLIC HEALTH SIGNIFICANCE
4. Describe your experience with the medical condition (disease) and/or proposed intervention
and/or service relating to the application summary.
RANZCOG members are involved in the care of people who are non-binary, gender diverse or
transgendered in both public and private settings. This cohort of patients seek care from RANZCOG
members for a range of concerns including abnormal uterine bleeding due to testosterone
administration, abnormal uterine bleeding, complications that have arisen from previous surgery
(often completed overseas) or persistent pelvic pain. Our members are also consulted for guidance
or requests related to tubal ligation, tube removal, or hysterectomy.
For adults in the public system, our members report less interaction with a hospital
multidisciplinary team, and a strong patient reliance on a supportive GP, mental health practitioner
and endocrinologist. In many cases, this cohort has been living in their trans body for many years.
In instances of chronic pelvic pain, abnormal bleeding, or for the transwomen, problems with
dyspareunia, clinicians provide care similar to that provided to cis-women.
To comply with international SoC/guidelines and ensure appropriate care for patients requesting a
hysterectomy, practitioners are required to ensure an adequate mental health assessment has been
performed. Practitioners must seek two letters from clinicians who have known the patient and
support their decisions regarding a hysterectomy. At present, a hysterectomy is funded under the
CARE
Medicare system.
UNDER
1982
For younger patients in the public setting such as in a gynaecology outpatient clinic, our members
AGED
consult as part of a multidisciplinary team in paediatric hospitals.
ACT
In the private setting, younger patients on occasion present to our members whilst waiting to be
AND
seen by a gender service. Many are distressed by their menses and
RELEASED
require care and support.
5. What do you see as the benefit(s) of the proposed medical service, in particular for the person
BEEN HEALTH
involved and/or their family and carers?
HAS INFORMATION
OF
The application outlines the importance of a multidisciplinary care team for those experiencing
gender incongruence, but RANZCOG believe
OF
s that this type of support is critical for all complex
presentations, not just those with gender incongruence. In many cases the surgical requirement for
this cohort is no more complex than those surrounding cis-women. Whilst RANZCOG do not support
the creation of specialised MBS items, the College does support the extension of current MBS items
DOCUMENT
to compensate for the ‘complexities’ and counselli
DEPARTMENT
ng involved in genealogical consultations and
FREEDOM
surgery. RANZCOG advocate for this code must be made available for use with all complex
THIS
presentations not just those invo
THE
lving gender incongruence.
THE
BY
Complex patients presenting with multiple health problems, such as intellectual disabilities,
epilepsy, abnormal uterine bleeding or chronic pelvic pain need to have equal access to MBS items,
such as item 133. At present gynaecologists are severely underfunded, receiving effectively half of
that a physician would when consulting with a patient with complex comorbidities.
RANZCOG believes that all people deserve equal access to publicly funded care. The College
cautions against the creation of a specialised code to be made available only to those experiencing
gender incongruence. The equivalent funding needs to be made available for intersex and cis-
women living with complex gynaecological presentations.
It is important to acknowledge that in Melbourne the reported out of pocket cost for a patient
electing to have top surgery is $10,000. Whilst the care provided is first-rate, the cost is out of reach
for many.
It must be noted that for those seeking interventions such as a hysterectomy, public Medicare
funding is available with no indication for surgery required, however waiting lists impede access for
many.
3 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
6. What do you see as the disadvantage(s) of the proposed medical service, in particular for the
person involved and/or their family and carers?
The College does not recommend establishing a specialised code for gender affirmation surgery
given there is already a reluctance to provide this service in the public setting. If the public hospitals
are unable or unwilling to provide publicly funded gender affirmation surgery, this code may only
have the effect of slightly reducing the costs associated with private surgery.
Those experiencing gender incongruence should not be singled out. Many interventions for this
cohort are straightforward and do not warrant a specialised code that attracts a higher rebate.
Instead, a higher rebate would be far more impactful if made available to all complex, multifaceted
patient presentations.
As stated above, RANZCOG advocate for equity of access for all. A patient requesting a
hysterectomy who is experiencing abnormal bleeding and pain should be treated and funded
equally regardless of their gender. The healthcare system would benefit far more from an equitable
approach.
7. What other benefits can you see from having this intervention publicly funded?
CARE
RANZCOG see little benefit in isolating a specific cohort and restricting fundi
UNDER
ng from those who
need it. All complex patients deserve to be funded equally regardless of their gender.
1982
AGED
Currently, most operations related to gender affirmation are carried out in the private health
ACT
setting. Whilst it is possible for public hospitals to provide these types o
AND
f gender affirmation
RELEASED
services, there may not be a substantial interest in doing so.
RANZCOG caution that even if public funding is mad
BEEN
e available, whilst it may have a positive effect
HEALTH
on availability of services, it would be at the discretion of each public hospital to determine their
capacity to provide the service.
HAS INFORMATION
OF
8. What other services do you believe nee
OF
d to be delivered before or after this intervention, e.g.
Dietician, Pathology etc?
RANZCOG support the idea of continuity of care following gender affirming surgery in the public
system. The College suggest the inclusi
DOCUMENT
on of funding for a single nurse to provide consistence care
following surgery of this type if a specific MBS item
DEPARTMENT
is to be created.
FREEDOM
THIS THE
Additionally, the College ad
THE
vocates for funding that allows a comprehensive model of care.
Complex, multifaceted presen
BY
tations may require funding for physiotherapy, psychologists,
dieticians or exercise physiologists. However, these services should be funded for all patients not
just those experiencing gender incongruence.
PART 3 – INDICATION(S) FOR THE PROPOSED MEDICAL
SERVICE AND CLINICAL CLAIM
9. Do you agree or disagree with the proposed population(s) for the proposed medical service?
☒Strongly Agree
☐Agree
☐Disagree
☒Strongly Disagree
Specify why or why not:
4 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
The College strongly advocate for equitable funding models for all people, not just those
experience gender incongruence. RANZCOG acknowledge that there are many individuals
who need access to comprehensive care and that the trans population represent only one
such group. The MBS should support equitable access for all people, not just a select group.
However, RANZCOG recognise that the unaffordable costs associated with private gender
affirming surgery leads many to seek care overseas. The risks of having surgery in countries
with lower health care standards increases the risk of post operative complications for this
cohort.
10. Have all the associated interventions been adequately captured in the application summary?
☒
Yes
☐
No
Please explain:
RANZCOG has no additional feedback.
11. Do you agree or disagree that the comparator(s) to the proposed medical service?
CARE
UNDER
☐Strongly Agree
1982
☒Agree
AGED
☐Disagree
ACT
☐
AND
Strongly Disagree
RELEASED
Please explain:
BEEN HEALTH
RANZCOG has no additional feedback.
HAS INFORMATION
OF
12. Do you agree or disagree with the clinical claim made for the proposed medical service?
OF
☐Strongly Agree
☒Agree
☐Disagree
DOCUMENT
☐
DEPARTMENT
Strongly Disagree FREEDOM
THIS
THE THE
Specify why or why not:
BY
The provision of a specific MBS item number may improve access to surgical treatment of a
medical disorder, however this will only support one cohort, leaving many underserved.
5 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
PART 4 – COST INFORMATION FOR THE PROPOSED MEDICAL
SERVICE
13.
Do you agree with the proposed service descriptor?
☐Strongly Agree
☐Agree
☐Disagree
☐Strongly Disagree
Specify why or why not:
CARE
14.
Do you agree with the proposed service fee?
UNDER
1982
☐Strongly Agree
AGED
☐Agree
ACT
☐Disagree
RELEASED AND
☐Strongly Disagree
BEEN
Specify why or why not:
HEALTH
HAS INFORMATION
OF
OF
DOCUMENT
DEPARTMENT
FREEDOM
THIS
THE THE
BY
6 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
FOI 4876 - Document 26
PART 5 – ADDITIONAL COMMENTS
15. Do you have any additional comments on the proposed intervention and/or medical condition
(disease) relating to the proposed medical service?
16. Do you have any comments on this feedback survey? Please provide comments or suggestions
on how this process could be improved.
UNDER CARE
1982
AGED
ACT
RELEASED AND
BEEN
Again, thank you for taking the time to provide val
HEALTH
uable feedback.
HAS INFORMATION
OF
OF
DOCUMENT
FREEDOM
DEPARTMENT
THIS
THE THE
BY
7 | C o n s u l t a t i o n S u r v e y o n t h e A p p l i c a t i o n S u m m a r y a n d P I C O S e t a n d / o r
P I C O C o n f i r m a t i o n
( N e w a n d A m e n d e d R e q u e s t s f o r P u b l i c F u n d i n g )
