Part 1. The Guidelines for Trans and Gender Diverse Children and Adolescents

Introduction

This week Australia’s Royal Children’s Hospital Gender Service has launched the “Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents”. These guidelines are compiled by the leading Australian experts, based on the best and most current evidence from around the world. These guidelines are endorsed by ANZPATH (the Australian and New Zealand Professional Association for Transgender Health) and were launched at the recent ANZPATH conference. They are now the official guidelines for all health professionals working with transgender children in Australia.

The standard is clearly written and concise and it is definitely worth reading in full. Here,  for convenience, please find below a brief synopsis of selected key extracts from the document. In Part 2 we will look at Why this standard matters, and why it should be adopted in the UK NHS.

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents (pdf)

 

Key extracts from the document:

Evidence Based:

“Recommendations are made based on available empirical evidence and clinician consensus”, “developed in consultation with professionals….from multiple disciplines, trans and gender diverse support organisations, as well as trans children and adolescents and their families”.

Numbers expected to increase:

“with increasing visibility and social acceptance of gender diversity in Australia, more children and adolescents are presenting ….requesting support, advice, and gender affirmative psychological and medical treatment”. with “approximately 1.2% of adolescents identifying as trans” “it is likely that referrals. ….will continue to rise in the future”.

Natural:

“being trans or gender diverse is now largely viewed as being part of the natural spectrum of human diversity”.

(This Australian guidance was completed before the latest Endocrinology guidelines, stating that “there is a durable biological underpinning to gender identity”.

Affirmative care:

“increasing evidence demonstrates that with supportive, gender affirmative care during childhood and adolescence, harms can be ameliorated and mental health and well being outcomes can be significantly improved”.

General principles for supporting trans and gender diverse children and adolescents

• “Individualise care”. Emphasises the “importance of tailoring interventions”, recognising each individual’s “unique clinical presentation” and “individual needs”.

• “Decision making should be driven by the child or adolescent wherever possible, this applies to options regarding not only medical interventions but also social transition”.

• “Use respectful and affirming language”.

• “Avoid causing harm”. “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications”

• “consider legal requirements” outlines legal requirements that are barriers to “obtaining identity documents that accurately reflects their gender”. Considers “implications for young people’s right to privacy and confidentiality when enrolling in school or applying for work”.

Children vs adolescents:

“the clinical needs (of children vs adolescents) are inherently different, and consequently we provide separate guidelines for trans and gender diverse children and adolescents”

Psychological Support for a younger child:

• “Supporting trans and gender diverse children requires a developmentally appropriate and gender affirming approach”.

• “for children, family support is associated with more optimal mental health outcomes”

• “trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life such as the family’s general practitioner or school support”.

• “others may benefit from a skilled clinician working together with family members to help develop a common understanding of the child’s experience”.

• “when a child’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties …. a more intensive approach with input from a mental health professional will be required”.

Social Transition for a younger child:

• “social transition should be led by the child and does not have to take an all or nothing approach”.

• “provision of education about social transition to the child’s kindergarten or school is often necessary to support a child who is socially transitioning to help facilitate the transition and minimise …bullying or discrimination”.

• “social transition can reduce a child’s distress and improve their emotional functioning. Evidence suggest that trans children who have socially transitioned demonstrate levels of depression, anxiety and self-worth comparable to their cisgender peers”.

• “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

Key roles for a clinician of younger child:

• Supportive exploration of gender identity over time

• Work with family to ensure a supportive home environment

• Advocacy to ensure gender affirming support at school

• Education (to child and family) on gender identity and signposting to support organisations for child and for parents

• If child is expressing desire to live in a role consistent with their gender identity, provision of psycho-social support and practical assistance to the child and family to facilitate social transition

• Referral to endocrinologist ideally prior to onset of puberty

Supporting Adolescents:

[For] “adolescents with insistent, persistent and consistent gender diverse expression, a supportive family, affirming educational environment and an absence of co-existing mental health difficulties, the adolescent and parents may benefit from an initial assessment followed by intermittent consultations with a mental health clinician”

Supporting Parents of Adolescents:

“adolescents often encounter resistance from their parents when their trans or gender diverse identity is first disclosed during adolescence”. “For the clinician, investing time for parent support… will assist in creating a shared understanding….and enable optimisation of clinical outcomes and family functioning”

Fertility Counselling for Adolescents:

“Although puberty suppression medication is reversible and should not in itself affect long term fertility, it is very rare for an adolescent to want to cease this treatment to conduct fertility preserving interventions prior to commencing gender affirming hormones. It is therefore necessary for counselling to be conducted prior to commencement of puberty suppression or gender affirming hormones”

Commencement of puberty suppression

“Puberty suppression is most effective in preventing the development of secondary sexual characteristics when commenced at Tanner stage 2”. ”reduction in the duration of use of puberty suppression by earlier commencement of stage 2 treatment must be considered in adolescents with reduced bone density to minimise negative effects.”

Commencement of gender affirming hormone treatment

• “The ideal time for commencement of stage 2 treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances” “adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios”. “The timing…will also depend on the nature of the history and presentation of the person’s gender dysphoria, duration of time on puberty suppression for those undertaking stage 1 treatment, co-existing mental health and medical issues and existing family support”

• “While later commencement of hormone treatment during adolescence provides time for further emotional maturation and potentially lessens the risk that the adolescent will regret their decision, this should be carefully balanced by the biological, psychological and social costs to the adolescent of delaying treatment”.  “Biological implications of delaying hormones include ….relative osteopenia, and (for) trans females …linear growth…” “Psychological costs may include the negative contribution treatment delay may have on an adolescent’s sense of autonomy and agency, and may contribute to, or exacerbate, distress, anxiety or depression with subsequent increase in self-harm or suicide risk”. “Social costs of delayed treatment include peer group and relationship difficulties with pubertal development occurring significantly behind expected norms”

Surgical interventions

• “Chest reconstructive surgery may be appropriate in the care of trans males during adolescence”.

•  “delaying genital surgery until adulthood is advised”

Transition of care to adult care providers

“the young person’s GP is vital in facilitating a smooth process and many GPS continue as the primary doctor involved in hormone prescribing and monitoring of mental health after engaging in a shared care agreement during paediatric treatment”.

 

In Australian Standard of Care Part 2. (Below) we discuss:

• Why this standard matters, 
• Why it should be adopted in the UK NHS
• A comparison between the Australian Standard and UK Service Specification
• A comparative analysis of the evidence base underpinning the Australian and UK approaches