20 June 2018

National guidelines for care of transgender kids

Clinical Paediatrics

Transgender children now have their own Australian guidelines, which stand in favour of surgery to align them with the gender they identify as.

The new guidelines ask doctors to be sensitive and respectful of the way someone would prefer to be addressed, such as the name and gender they would like to be used, and to tailor care to each individual.

The guidelines opt for a psychological approach to assessing whether a patient is right for medical or surgical interventions, rather than the previous chronological one. However, parents and legal guardians have the power to provide consent for the procedures.

 “Being transgender or gender diverse is now largely viewed as part of the natural spectrum of human diversity,” the guidelines, published in the MJA by Associate Professor Michelle Telfer and colleagues, said. 

“It is, however, frequently accompanied by gender dysphoria, the distress that arises from incongruence between a person’s gender identity and their sex assigned at birth.”

As society became more comfortable and accepting of transgender people, clinicians were likely to encounter more patients requesting care, Professor Telfer, the director of the Royal Children’s Hospital Gender Service, said.

“It has been estimated that about 1.2% of Australian adolescents identify as transgender, and it is therefore likely that referrals to healthcare professionals will continue to rise in the foreseeable future,” Professor Telfer, who is also acting president of the Australian and NZ Professional Association for Transgender Health, said in a statement. 

Four out of every five transgender or gender diverse young people has self-harmed and half have attempted suicide. 

While many are now familiar with the term transgender, referring to someone whose gender identity does not match up with the sex they had at birth, gender diverse refers to the broader umbrella of individuals who don’t fall in line with traditional gender expectations. 

This may include non-binary people, who do not see themselves as exclusively male or female, and agender people, who do not see themselves as any gender.

Up until now, previous international guidelines failed to adequately address Australia’s unique culture and geographic barriers when it came to care, the authors wrote. 

Instead, the new guidelines provide a legal perspective and encouragement to be aware of additional barriers to treatment that Indigenous and other culturally and linguistically diverse individuals may face. 

Under the law, clinicians themselves can make the judgment on whether the patient has provided informed consent, and initiate hormone therapy without court authorisation. 

For pubescent adolescents, a number of additional services may be of use. These include: fertility training, voice training, and puberty suppression, followed by hormone affirmation therapy such as oestrogen or testosterone and/or surgery. 

“The main concern with use of puberty suppression from early puberty is its impact on bone mineral density owing to the absence of the effect of oestrogen or testosterone on bone mineralisation,” the authors said. 

Genital and chest reconstructive surgery are obviously more invasive, and so should be carefully considered in consultation with a clinician experienced in trans care. 

They advise genital surgery be delayed until age 18. 

MJA 2018, online 18 June