Care of trans, gender-diverse and non-binary children and adolescents

By Dr. Julia K. Moore MBBS (Hons), FRANZCP, Cert Child Adolescent Psychiatry Consultant Child and Adolescent Psychiatrist, CAHS Gender Diversity Service

The HealthPathways WA Transgender Health and Gender Diversity HealthPathway is now LIVE.

Transgender health care across the life span is a core area of clinical skills for all health professionals.  Trans and gender diverse people have always been around, evident in culture, language and history from around the world, for example Indigenous Brotherboys and Sistergirls, Maori whakawāhine and tangata ira tāne, Samoan fa’afafine and fa’atane, and Indian Hijra people. Medical understanding has progressed from past stigmatizing perceptions of gender diverse people as “disordered” or “confused”, to now recognising the spectrum of gender as a normal part of human diversity. Transgender health care is not new, hormonal and surgical treatments were offered to adults in Berlin in 1918, and the treatment of gender-dysphoric adolescents with puberty suppression and hormone treatments commenced in the Netherlands around 1991. People may first express gender dysphoria or transgender identity at any life stage.  The US Transgender Survey (2015) of 27,715 adults found that 15 per cent first told someone that they were transgender under age 15, and 37 per cent between age 16 and 20 – even before social media and increased awareness of gender diversity, “coming out” in adolescence was frequent. Identifying as non-binary is increasingly frequent. It is important to understand that some people are trans, and this is OK. “Conversion therapy”, or efforts to deliberately change gender identity or sexual orientation, is ineffective, harmful, and unethical. Some trans and gender diverse people request medical or surgical gender-affirming treatment and experience it as medically essential; some do not want treatment. Treatment decisions are led by the person’s expressed wishes and needs.

It is normal and healthy for children to have interests, activities and friendships that do not conform to cultural ideas of “masculine” and “feminine”. This doesn’t need assessment or diagnosis. Some children are distressed by their sex registered at birth, and make strong statements, wishing to live as their identified gender, at home and school. Observational evidence and clinical experience indicate that this child-led social transition is associated with positive psychosocial outcomes. This is a family decision, which should be led by the child’s expressed wishes, not imposed by adults.  No medical or surgical treatment is offered for gender dysphoria before puberty commences. Prepubertal children only need love, support, and listening.  Some become comfortable with their birth-registered sex and gender during late childhood to early puberty, so it is important that children who socially transition are supported to “change back” at any time they wish. In childhood and adolescence, it is important to facilitate access to mental health care for common problems including social anxiety, depression and suicidality, autism and ADHD if present, alongside gender-affirming care.

Puberty suppression with gonadotropin releasing hormone agonists can be indicated when gender dysphoria continues through to adolescence, with distress at the body changes of early puberty.  Puberty suppression is ideally commenced at Tanner stage 2 – 3, early enough to provide long-term benefit by preventing breast development or voice deepening and facial masculinisation.

Some young people first experience gender dysphoria peripubertally; this is common, and puberty suppression may still be offered to provide relief of distress and allow time for clarification of identity and wishes. A person can decide to stop puberty suppression at any time, and its effects are largely reversible. Most people who start puberty suppression remain stable in their gender identity, and go on to testosterone or oestrogen gender-affirming treatment in later adolescence or young adulthood

Oestrogen/anti-androgen and testosterone treatment can be provided to more mature adolescents with long-term stable gender identity, who have developed the capacity to give informed consent to these treatments, including appreciation of the risk of regret. This requires repeated consultations, and specific counselling regarding fertility.  Many do not have preceding puberty suppression. Masculinising chest reconstruction is sometimes done under age 18 but is not provided in the public health system in WA. Genital surgery is not done under age 18 in Australia. Many trans people do not want genital surgery, but for some it is extremely important.

The treating medical practitioner must obtain the active informed consent of all legal guardians before providing gender-affirming puberty suppression, oestrogen, testosterone, or surgical treatment for a person under age 18, regardless of whether the young person is Gillick competent, according to the Family Court of Australia judgement Re: Imogen [2020]. The risks of any treatment need to be weighed against the risks of having no treatment.  Withholding treatment against a young person’s wishes is not a neutral option.

The CAHS Gender Diversity Service (GDS), based at Perth Children’s Hospital, is a multidisciplinary team that provides information, support, links to other services, assessment, and (where wished-for and appropriate) gender-affirming medical treatment with puberty suppression, oestrogen and testosterone in liaison with the adolescent’s general practitioner. Unfortunately, GDS referrals far exceed capacity, and many older adolescents can’t be seen before they “age out” of the paediatric service wait list.

There is a pressing need to develop capacity in WA for gender-affirming care of adolescents and young adults outside of the single hospital specialist setting. Models exist in other states for treatment in primary care with collaboration between GPs and psychologists, with other specialist consultation as appropriate. GPs can help to support open communication and improve understanding between parents and young people. Providing accurate information often helps relieve family anxieties. Peer support from other parents, through TransFolk of WA or Transcend Australia, is very helpful.

Supporting trans, gender diverse and non-binary people to access appropriate and inclusive healthcare