A LANDMARK legal decision in November 2017 dramatically changed the landscape in the medical treatment of transgender and gender diverse (TGD) children in Australia. The judgement, handed down from the Family Court, ruled that TGD teenagers seeking gender-affirming hormone treatment no longer need authorisation from the Court, as long as their parents and treating doctors give their permission. The decision has been seen as sign that things are finally starting to move in the right direction in the recognition of TGD issues in Australia.
Now, hot on the heels of that breakthrough, we have the first-ever Australian guidelines for the medical care and treatment of TGD children, a summary of which is published by the MJA. The guidelines are endorsed by the Australian and New Zealand Professional Association for Transgender Health.
The guideline authors say that with supportive, gender-affirming care during childhood and adolescence, major harms can be avoided and the mental health and wellbeing outcomes of TGD children substantially improved. It offers recommendations for the psychological support of TGD children both before and after the onset of puberty, as well as best practice around such issues as puberty suppression treatment, fertility counselling, gender-affirming hormone treatment using oestrogen and testosterone, and surgical interventions for TGD adolescents.
Lead author Associate Professor Michelle Telfer, who is Director of the Gender Service at the Royal Children’s Hospital Melbourne, says that of the two international guidelines already in existence, one is out of date and the other, from the Endocrine Society, is very detailed in terms of endocrine management but doesn’t delve into the more general aspects of care.
“We wanted to have a guideline available that was really relevant to our clinical practice, and none of the others do that,” she told MJA InSight in an exclusive podcast.
Dr Telfer says that the best estimate of the number of transgender children in the population comes from a 2014 New Zealand study of over 8000 high school students, of whom 1.2% identified themselves as being transgender, with a further 2.5% saying they were unsure of their gender.
What is certain is that the number of children presenting to doctors with questions about their gender has increased substantially over the past decade.
“We had our first referral at the Royal Children’s Hospital in Melbourne in 2003, and until 2007 we only had three referrals in total. But last year we had 253 referrals within 12 months and in 2018 we’re heading towards 300.”
Dr Telfer puts that down to the increased visibility and acceptance of transgender people, and an environment where people are much more comfortable talking about their experience of gender than in previous generations. She says that her clinic has seen children as young as 3 years, brought in by parents who are unsure what to do when their child has expressed their thoughts about their gender.
“People say, how could they know when they’re that young? But if you ask any 3-year-old if they’re a boy or a girl, they’ll tell you in no uncertain terms. We have 2- or 3-year-olds who verbalise very clearly how they feel about their gender, and we listen. We don’t necessarily intervene at that age, but what is very clear from the research that’s coming out both in Australia and internationally is if you support the child to express themselves and be who they are, their long term mental health outcomes are very good and actually equivalent to the general population.”
Indeed, one of the key messages from recent research in young transgender people is the high cost they pay in terms of mental health when they are not adequately supported. A study of 859 young transgender Australians published last year found that 80% had engaged at least once in self harm and, shockingly, almost half had attempted suicide.
One of the co-authors of that study is psychologist Sam Winter, an Associate Professor at the School of Public Health at Curtin University and a board member of the World Professional Association for Transgender Health.
Dr Winter, who welcomes the publication of the new guidelines, says that one of the challenges for young transgender people navigating their way through the medical world is that the GPs, who are often the first port of call, don’t necessarily feel up to the task.
“Doctors often feel they’re ill-equipped and that they don’t understand the nature of what these kids are going through. A lot of GPs are perhaps unduly anxious and scared of working with these patients. We have such a history of regarding transgender people as this very specialised group and that we need to refer them on, as quickly as possible. That’s a mindset family practitioners need to discard. These are kids they’re going to meet, and they should learn to be comfortable with them and their families.”
He says the guiding principle is that TGD children need to be recognised as simply growing up differently, and that this is something that should be supported, rather than problematised.
“One should be affirmative, respectful, treat the child with dignity and use the pronouns that the child prefers. Parents and doctors should realise that if they don’t support their kid and allow them the space to explore who they are, they could end up depressed, anxious and even suicidal, because we know that’s what happens when these children aren’t supported.”
Dr Winter says that there are still plenty of doctors who take the view that these children have a disorder, rather than simply being different.
“Transgender health has not been taught in our medical schools and is still not taught. There’s a real task of education, particularly for GPs who tend to be the first point of contact. Doctors need to have a basic understanding that what they’re dealing with in TGD kids is diversity, not a disorder.”
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