3 October 2018

Transgender children: When doing nothing causes harm

Clinical Paediatrics

Last month, Australia’s newest prime minister responded to a tabloid media story by tweeting this: “We do not need ‘gender whisperers’ in our schools. Let kids be kids.”

Jo (not her real name), the mother of a transgender child in NSW, says this was the prime minister giving “the whole of Australia permission to kick us in the guts”. 

The Coalition’s Scott Morrison had only been in office for 13 days when he handed a megaphone to transphobics and transsceptics by endorsing the provocative news story in Sydney’s Daily Telegraph.

The newspaper had incorrectly claimed that teachers were being “taught to spot potential transgender students”, leading to a “236% surge” in the number of children wanting to change their gender in the past three years. 

The number of transgender children coming out is certainly increasing dramatically, but not for the reasons stated in the story, says counsellor Dr Elizabeth Riley (PhD). 

The number of transgender children is the same as it ever was – around 1.2% of the population; kids just feel safer identifying as trans now that there is greater awareness and acceptance in society, she says.

The Royal Children’s Hospital in Melbourne, which runs Australia’s leading Gender Service, has seen an increase in referrals from one patient every two years in 2003 to 104 new patients being referred in 2014. 

The school counsellors quoted by the newspaper, of whom Dr Riley is one, have clarified that they do not train teachers to spot trans students. 

The Gender Centre, a NSW counselling service, says it only offers training to schools about how to accommodate the needs of existing trans students with the involvement of parents. 

Claims that teachers were being taught to recognise phrases such as “I feel different”, “I’m androgynous” and “I’m born with two spirits” as an indication of a child’s hidden transgender identity, have been refuted.

According to Dr Riley, this claim has absolutely no basis. Those phrases were lifted from a survey of transgender adults and had nothing to do with children at all, she says. 

Moral panic tends to break out among the far right whenever LGBTQI+ support services are expanded, Dr Brad McKay, a Sydney GP, says. 

Some conservatives fear that children are being secretly groomed by evangelical queer people with some kind of trans agenda. 

This is incredibly tragic because we know that trans kids who are left to fend for themselves are among the most vulnerable members of the community, he says.

A recent Australian survey of around 850 transgender people aged 14-25 years found that 48.1% had attempted suicide, and that trans kids were 10 times more likely than their peers to have depression or anxiety. 

Trans kids are, on average, 12.3 years old when they present to The Royal Children’s Hospital, with most reporting gender concerns from the age of three or four years.

It’s normal for pre-schoolers and primary school kids to cross gender boundaries, but how do parents distinguish the “tomboys” or “janegirls” from transgender children? 

“A transgender child is something different,” Eloise Brook, a spokesperson for the Gender Centre in NSW, says.

“There’s a different degree here. This is something that is deeply-felt and long-lasting.” 

Fortunately, there are no known harms associated with letting children socially transition to a different gender at any age.

There is no medical treatment anywhere in the world for transgender children before the age of puberty. A lot of time passes before any medical decisions need to be made.

Some kids will socially transition by changing their pronouns, name and appearance during childhood and then revert back to their gender assigned at birth as they mature. 

Others will persistently and consistently identify as a different gender – these kids are considered transgender, or gender diverse. 

While it’s natural for some parents to be a little anxious about raising a gender-diverse child, “a little bit of the heat comes out of it when you have to live it day by day”, says Ms Brook. 

This may not come as a shock to most parents, but if trans children are not pathologised or reprimanded for crossing gender boundaries, the evidence shows that they grow up with a healthy sense self and have mental health outcomes comparable to their peers.

Parents may fear that a child will make themselves a target for schoolyard bullies if they transition to a different gender – but it’s not that black and white, says Ms Brook.

Two teachers at different NSW schools told The Medical Republic that the classmates of transgender children were overwhelmingly supportive – and even went as far as correcting the teacher if they used the wrong pronouns!

“Some of the [trans kids] are completely oblivious,” says Dr Riley. “I had a little 11-year old sitting in my office and she flipped her hair back and said, ‘I don’t know what all the fuss is about’. 

“And she had two younger brothers and she’d been assigned as a boy at birth. The parents had protected her and she had socially transitioned at school and the kids had a party for her. They celebrated it with her.”

According to Ms Brook, that does not mean there is no bullying going on. But it usually comes from people outside the school community who don’t know that child’s story.

One family told Ms Brook that they were being forced to move house because their child was being bullied in the street by kids from other schools.

What parents want from their GPs 

Transgender medicine can be bewildering for some GPs, says Dr McKay, but patients will be quite understanding of doctors who are honest about their lack of knowledge and are willing to learn as they go.

“It’s not that GPs have to know the ins and outs of absolutely everything,” says Jo, who has a transgender son. “There are some really basic things like when somebody comes into your practice and tells you their name is Tom, if their Medicare card says Sue, call them bloody Tom, not Sue.”

GPs can really be the “lynchpin in the whole process for these kids”, says Dr Fiona Bisshop, a Queensland GP with an interest in gender.  

GPs can rally family support, provide advocacy at school, monitor mental health, help update identity documents and provide advice about suppressing menstruation, contraception, fertility preservation and sexuality. 

There are only a handful of publicly funded gender clinics in Australia, and the waiting lists are long, so trans patients often depend on GPs to coordinate care with endocrinologists and psychiatrists in private practice.

“My son transitioned eight years ago and services were very, very limited and we basically had to doctor shop to find somebody that could help us,” says Jo. 

Jo has heard of families having to drive seven and a half hours from the township of Hay, in rural NSW, to get support for a transgender child at a Sydney clinic. 

When her son was sick and missed a specialist appointment, Jo had to call 15 GPs to find one that would prescribe cross sex hormones, even though every GP in the country has the power to issue a repeat prescription of testosterone and oestrogen with a simple phone call to the PBS.

“There’s no need for basic treatments to be as outrageously difficult as they are,” says Jo. 

What the guidelines say

Australia now has clinical guidelines – published this year by the Royal Children’s Hospital in Melbourne – which state that “withholding of gender-affirming treatment is not considered a neutral option” as it may exacerbate distress, depression, anxiety or suicidality.

These guidelines were created in consultation with all the known psychiatrists, paediatricians and paediatric endocrinologists who work in the area of child transgender health across the nation.

Puberty can be traumatic for trans children with gender dysphoria (the distress that is often associated with identifying as a gender that is different to your sex assigned at birth), so puberty blockers can be used to halt physical changes such as voice deepening, facial hair and breast development. 

The effects of puberty blockers are reversible. The earliest that puberty blockers (stage one treatment) will be considered is at Tanner stage two, which is the beginning of breast buds in girls and the beginning of testicular enlargement in boys. The timing differs from child to child, but is usually initialled around the age of 10 years.

Until last year, families had to apply to the Family Court to get access to puberty suppression and hormonal treatment. 

The court case Re: Kelvin (2017) challenged this law, allowing the doctors and the parents to decide if a medical transition was in the best interests of the child.

Puberty blockers give the child time to mature emotionally and cognitively before making a decision about whether they want stage 2 treatment with cross sex hormones, which have irreversible effects. 

Not all trans people choose to transition medically; around 30% have used hormones, and an additional 34% want to use hormones in the future. Being on puberty blockers too long can affect bone mineral density, so doctors will generally monitor patients and recommend and earlier initiation of testosterone or oestrogen if necessary.

The issue of fertility preservation can be a thorny one. Oestrogen causes infertility in trans women, but transgender children often don’t want to wait until their sperm is mature enough to undergo cryopreservation before starting puberty blockers because this coincides with voice deepening. 

A child aged 10 is unlikely to be thinking very deeply about their desire to have a family in the future, but parents may be anxious for their child to avoid making any decisions that they later come to regret, says Ms Brook. 

“I think there is probably too much focus on it,” she says. “Young trans people transition because they feel like they are swimming to save their lives. And sometimes if you are swimming to save your life and your parent is saving, ‘think of your children or your grandchildren’, it’s like, ‘no, you know what? I’m just going to think about not drowning’.”

Gender-affirming surgery is very rare for people under the age of 18 in Australia; there was one case of breast reconstruction in a 15-year old in 2016. Genital reconstruction in those under 18 is generally not considered.

In Australia, around 7% of trans people have undergone gender-affirming surgery and 21% of trans people intend to.

All surgery comes with risk, so the decision is not taken lightly, says Jo. 

But you can see why surgery might be in the best interest of some trans boys who wear restrictive binders, she says. “I know people who have cracked ribs they have worn binders for so long. I know children that shower in the dark with their binder on. 

“Then there are children that don’t shower at all because they can’t take off their clothes.”

The unknowns

Much of this guidance is medically uncontroversial; no reasonable person would disagree that respectful, gender-affirming care is appropriate for children. 

However, some doctors outside of the field of transgender medicine are worried that there is not enough evidence to support medical transitions in teenagers.  

Perhaps the loudest voice is that of Professor John Whitehall, a paediatrician at Western Sydney University, who does not have any transgender patients of his own.

Professor Whitehall called medical transitions in children a “sad, tragic and very dangerous fad” in the Daily Telegraph’s story in which he was the only medical expert quoted.

“The current medical pathway for intervention in childhood gender dysphoria is a massive intrusion and I find it important to highlight other people’s research into its experimental nature,” Professor Whitehall tells The Medical Republic. 

Professor Whitehall is particularly concerned about the effect of cross sex hormones on the developing adolescent brain.

“It is known that transgendered people commit suicide … more frequently,” he says. “Proponents declare it is because of societal bullying, cynics wonder if they have tragically realised all the trouble [of a medical transition] has not made them happier.”

There have been no studies investigating the neurological effects of testosterone and oestrogen on trans teenagers, so Professor Whitehall’s comments are highly speculative. 

Medical treatments are usually rigorously tested in multiple RCTs with long-term follow-ups. But, as the authors of the Australian Standards of Care acknowledge, there are only a limited number of non-randomised clinical studies and observational studies to support their recommendations. 

The first systematic review of hormonal treatment in young people with gender dysphoria, published in Pediatrics this year, included just 13 studies, most of which were retrospective. 

The risk of bias in all studies was medium to high, due to small sample sizes and loss to follow-up.  One study included in the review was an eight-year Dutch trial published in 2014, which showed that gender dysphoria alleviated in 55 trans adolescents after treatment with puberty blockers (at age ~13), hormones (at age ~17) and gender reassignment surgery (at age ~21).

However, this study has not been replicated in an Australian context. 

Doctors who witness the transformation of their transgender patients first-hand are convinced that gender-affirming treatment can help.

Dr Bisshop watched a depressed, introverted young person on antidepressants who wasn’t attending school become dux in senior school and enrol in medicine at university “because they’ve been able to transition and just get on with their lives”. 

“It doesn’t matter what age you are when you come out,” she says. 

“It is the best day ever and it’s the start of a new life.”

Resources for GPs

The first Australian standards of care for transgender children and adolescents: bit.ly/2N5XQAe

The MJA article summarising the new standards of care: bit.ly/2QvA5j0

The first systematic review of hormonal treatment in young people with gender dysphoria: bit.ly/2p5MfCJ

The Trans GP Modulebit.ly/2QmB0m9

An eight-year Dutch study of 55 transgender adolescents after treatment with puberty blockers (at age ~13), hormones (at age ~17) and gender reassignment surgery (at age ~21) showing that gender dysphoria resolved (2014): bit.ly/2NIK6Lc

Statistics showing the very high rates of mental illness and suicide attempts in trans kids and teenagers in the Telethon Kids Institute’s Trans Pathways Report 2017: bit.ly/2OeXhRi

Opposing viewpoints

The Daily Telegraph article quoted in this story: bit.ly/2QqSnCg

Professor John Whitehall’s views recently published in the Quadrant (Experimenting on children with gender dysphoria: Does the “dutch protocol” offend the nuremberg code?): bit.ly/2QqDwaH

Special thanks to:

Gender Help for Parents Australia

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Ralph Vida
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Ralph Vida
2 months 1 day ago
The increase in RCH referrals to the gender service 2003-2014 is a disturbing statistic and showcases the rise in popularity of this reassignment consideration. I would respectfully suggest a gender neutral approach in school and clinical practice until emotional maturity is attained and then the discussions can begin in earnest and respectfully so. As perhaps an aside: LGBTIQ+ is the most ridiculous nonsense I have been exposed to in my 58 year lifetime – you either are attracted to the same, the opposite or both, and therefore cannot fall in love with anyone or anything else eg roller coasters etc… Read more »
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