The publication and use of a treatment guideline supporting the widespread prescription of puberty blockers and cross-sex hormones to minors has come under scrutiny following the recent accreditation process of the Royal Children’s Hospital (RCH) Melbourne. Documents obtained through a Freedom of Information (FOI) request reveal that the guideline was not reviewed as part of the hospital’s accreditation against the National Safety and Quality Health Service Standards in 2025.
May Low, senior legal counsel for RCH, confirmed that the Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents were not examined during the hospital’s “short-notice” assessment in August 2025. Hospital accreditation is a mandatory process designed to ensure patient safety and promote high-quality care by verifying that institutions employ best-practice guidelines.
Concerns about the guideline’s clinical governance were initially raised three months prior to accreditation by Alison Clayton, a senior psychiatrist and researcher, who questioned the processes underpinning the adoption of the puberty blocker-led protocol at RCH. First issued in 2018, the guideline advocates a gender-affirming approach, recommending that conditions such as psychosis, depression, anxiety, and autism in minors should not necessarily exclude them from medical transition treatments involving irreversible hormone therapy.
After its adoption, the guideline received retrospective approval from a majority of the hospital’s New Technology and Clinical Practice Committee, but FOI documents do not clarify how the RCH executive addressed governance issues related to this approval process. Dr. Clayton, affiliated with the Society for Evidence-based Gender Medicine, criticized the guideline for falling “far below international and national standards for trustworthy clinical guidelines.” She further noted that the 2025 accreditation did not interrogate the hospital’s clinical governance concerning the guideline, raising public concerns about safeguarding vulnerable young patients. Dr. Clayton called for an independent and thorough inquiry into both the guideline and the hospital’s governance arrangements.
Pediatrician Gary Geelhoed, formerly Western Australia’s chief medical officer, expressed sympathy for the hospital’s intent to relieve distress among gender-diverse youth but cautioned that emerging evidence indicates the affirmative approach may cause long-term harm. He described the hospital’s continued commitment to the model as creating a “hall of mirrors” effect, reflecting organizational challenges in reconsidering the treatment framework.
International assessments, including the UK’s Cass Review, have rated the RCH guideline very low for development rigor and independence, resulting in recommendations against its use. In response to ongoing debate and criticism, federal Health Minister Mark Butler initiated a comprehensive review in January 2025, led by the National Health and Medical Research Council (NHMRC). This project, intended to replace the RCH guideline with a national standard, involves experts including Ken Pang, a pediatrician linked directly to RCH’s gender clinic and co-author of the current guideline. The new NHMRC-endorsed guideline is not expected before 2028.
Until then, the existing RCH guideline continues to inform clinical practice for gender-diverse children across Australia’s pediatric hospitals, despite restrictions being placed on similar treatments in Queensland and several other jurisdictions overseas.
The Australian Commission on Safety and Quality in Health Care oversees the accreditation framework through its National Safety and Quality Health Service Standards, ensuring hospitals maintain systems for clinical governance and access to evidence-based care. However, the accreditation does not extend to evaluating the scientific evidence behind specific guidelines.
Notably, the commission’s board chair, neurologist Christine Kilpatrick, also chairs the RCH board and formerly served as the hospital’s chief executive during a period when the gender clinic at RCH notably expanded—new referrals surged from 18 in 2020, under the leadership of pediatrician Michelle Telfer, to 253 in 2017. The commission stated that Professor Kilpatrick had declared this dual role, recognizing the potential for conflicts of interest. The commission also noted it has not been requested to conduct any work relating to youth gender care.
The issues uncovered raise broader questions about the governance mechanisms ensuring that clinical guidelines meet accepted evidentiary standards, especially in sensitive areas such as treatment for gender dysphoria in minors. Both RCH and the Australian Commission on Safety and Quality in Health Care have been approached for comment.