Child-led gender guideline up for major revision
The first treatment guideline for gender dysphoric youth has been caught up in controversy
A contentious transgender treatment guideline specific to children and adolescents is to undergo a major revision amid growing international concern about the known and unknown risks of medicalised gender change for minors.
The project to update the 2018 guideline, issued by Australia’s biggest children’s hospital gender clinic, is expected to be discussed on Saturday, May 21, at the Darwin conference of the Australian Professional Association for Transgender Health (AusPATH).
In June 2018, the Lancet journal praised the new Australian guideline, noting it had broken from previous guidelines by endorsing “child-led” social transition before puberty, and advising individualised treatment rather than strict minimum ages for irreversible cross-sex hormones.
The “gender-affirming” guideline, from the Royal Children’s Hospital in Melbourne, reportedly played a crucial role in persuading Australia’s Family Court that medical science had advanced enough to make it safe to cut back judicial supervision of hormone treatment decisions with minors, putting more trust in gender clinicians.
However, after promotion of the RCH guideline as “Australian standards of care”, the document came under scrutiny in 2019 by The Australian newspaper, and by health professionals and parents worried about the international surge in minors, mostly female, rejecting their birth sex and seeking puberty blocker drugs, synthetic cross-sex hormones and in some cases surgery, such as mastectomy.
Starting with Finland in 2020 and followed by Sweden’s Karolinska University Hospital gender clinic the following year, there has been an international trend away from medical responses to youth gender dysphoria, a condition of distress over biological sex.
Systematic reviews of the medical literature have highlighted the weak evidence base for under-18 gender-affirming interventions. Landmark litigation against the United Kingdom’s Tavistock gender clinic, brought by detransitioner Keira Bell, has sharpened the international focus on the risk of teenagers going ahead with irreversible medical treatment that they may come to regret.
Against this background, RCH gender clinic director Dr Michelle Telfer is understood to have announced that she will lead the revision of the 2018 Australian Standards of Care and Treatment Guidelines, which she and three of her colleagues authored.
The new guideline is expected to promote countrywide rollout of puberty blockers and cross-sex hormones, and national health professional bodies are to be asked to endorse the document.
Treatment guidelines, like policy statements from health professional bodies, have assumed an outsize role in the debate about the gender-affirming approach because of the lack of good quality research supporting its medical and psychological interventions.
The Society for Evidence-based Gender Medicine (SEGM), which champions a higher standard of evidence for treating gender dysphoric youth, said a credible guideline had to be built on the best available evidence identified by a rigorous systematic review of the medical literature.
“Given the significant shift that has occurred in the field of paediatric gender medicine in recent years, with many more children transitioning, and a growing body of evidence emerging not just about the potential benefits but also the potential risks, a systematic review of the evidence is a crucial step that cannot be omitted,” a spokeswoman for SEGM told GCN.
Genspect, a group opposed to the “affirmation-only” mindset and representing parents of gender-questioning children, said those involved in updating the Australian treatment guideline should take account of new, psychotherapy-first policies in Finland and Sweden, as well as the alarm bells rung by the UK Cass review into youth gender dysphoria care.
“As the interim Cass report notes, there are many pathways into and out of gender dysphoria, with medical transition or social transition being only one of many options,” a Genspect spokesman said.
“A recent study on social transition underscores the fact that using alternative names and pronouns for young children [in social transition] likely solidifies a trans identity, when [earlier] research shows the majority of such youth will outgrow it, with many maturing into gay adults.”
SEGM also suggested the Australian guideline review panel should guard against gender-affirming groupthink by including clinicians who follow a more conservative approach to gender dysphoria, such as “watchful waiting” with younger patients or exploratory psychotherapy.
SEGM said the panel could seek the involvement of a representative from the Royal Australian and New Zealand College of Psychiatry, which recently adopted a more cautious policy on gender dysphoria, a policy alert to the “paucity of evidence” and the reality of expert disagreement.
Australia’s National Association of Practising Psychiatrists, under president Dr Philip Morris, has updated its guide on youth gender dysphoria, which says “there is no consensus that medical treatments such as the use of puberty-blocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psychosocial adjustment”.
The NAPP advises psychosocial interventions as first-line treatments, arguing that pre-existing factors such as family or mental health issues may underlie gender dysphoria and should be given attention first.
At the AusPATH conference in Darwin, the keynote speakers are to include the high-profile American physician Dr Johanna Olson-Kennedy, director of the gender clinic at Children’s Hospital Los Angeles. She will talk about “the landscape of gender-affirming care for youth in the United States”.
Dr Olson-Kennedy is lead author on a 2018 JAMA Pediatrics study reporting mental health benefits for “chest reconstruction” surgery (mastectomy) performed on 68 biological females who identify as male — 33 of them under age 18 and two aged 13.
SEGM said that for balance, the Australian guideline project should include not only trans people but also detransitioners as well as parents of children who “desist” from their trans or non-binary identity before going down the medical path.
The current RCH treatment guideline does not mention detransition. Last year, the clinic’s head of research, Dr Ken Pang, put his name to a journal letter saying that “the only relevant case of regret of which we are aware is Keira Bell [from the Tavistock case], although presumably there are others”.
Like other gender-affirming clinics, RCH has downplayed detransition, suggesting it is vanishingly rare — or is not “true detransition” but rather an abandonment of trans identity and treatment forced by “outside pressures”, such as parents, religion and discrimination.
The clinic has relied heavily on low rates of treatment regret reported from years past by Dutch researchers, but this may be misleading because data for a sizeable portion of ex-patients was missing. In any case, these dated studies may not be applicable to today’s different profile of patients and less cautious treatment approach.
In a 2021 study by U.S. public health researcher Dr Lisa Littman, only 24 per cent of a group of 100 detransitioners taking part in a survey said they had gone back to tell their clinicians they had stopped taking hormonal treatment.
Another recent study of 237 detransitioners reported that “lack of support from social surroundings” was the least common reason for detransition, the most common reasons being realisation that “my gender dysphoria was related to other issues” and health concerns.
The design of these two surveys means the results may not apply to detransitioners generally.
An audit of patients at the RCH Melbourne clinic, covering 2007-16, reported that most of the 359 patients presented at first as transgender (87.2 per cent). Over the audit period, 11.5 per cent of 356 patients changed their gender identity at least once.
The audit may give a distorted view of the clinic’s overall caseload and treatment regime because it predates the most dramatic growth in new referrals; most of a $6 million funding injection financing more clinicians and puberty blocker drugs; and the 2017 re Kelvin court decision allowing easier, quicker access to cross-sex hormones
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In the new RCH treatment guideline, the trade-offs of harms and benefits, and the underlying values in play, should be made explicit, according to SEGM, which says that a male-born patient who begins hormone suppression in early puberty, followed by cross-sex hormones, is likely to be sterilised and suffer impaired sexual function.
“How are the parents of a gender-dysphoric male child to make the decision whether to value more ‘passing’ facial features or body composition by taking puberty blockers (early in puberty, at Tanner stage 2, roughly age 11), with the strong possibility that the child may have to undergo more complex surgeries and may never be able to experience sexual desire or orgasm?,” the SEGM spokeswoman said.
“How does a 16-year-old gender dysphoric [natal] female balance the desire for a more flat chest, achievable now by a double mastectomy, with possible future regret over not being able to nurse an infant — regardless of whether or not this patient stays ‘trans-identified’ long-term?”
The current RCH guideline says that “most” boys who identify as girls will find it “unacceptable” to postpone puberty blocking drugs until they can produce mature sperm for storage in an attempt to safeguard future fertility.
The guideline acknowledges that cryopreservation of testicular tissue — the only option for a male child started early on puberty blockers — is experimental.
The document also flags the fact that early hormone suppression in boys cuts short the growth of penile and scrotal tissue available for surgical repurposing as a “neo-vagina”.
American trans surgeon Dr Marci Bowers told journalist Abigail Shrier last year about the obstacle to forming intimate relationships for these trans adults, such as reality TV star Jazz Jennings, who took puberty blockers early in their natural development and therefore had never experienced orgasm.
Guideline goes global
A sample of international commentary on the RCH guideline
June 2018, The Lancet journal | Unsigned editorial: “Spurred on by increasing acceptance of transgender individuals in society (and normalisation of the right for anyone to question their gender identity), the number of young people seeking support is likely to increase further. Children and adolescents with gender dysphoria often experience stigma, bullying, and abuse, resulting in high rates of mental illness, including depression, anxiety, and self-harm. But with supportive, gender-affirming management—as laid out by the Australian guidelines—these consequences can be minimised”.
December 2018, The Lancet | Letter from Professor Richard Byng and three other physicians: “The health of transgender children is addressed with imprecise language [“sex assigned at birth”] and overplayed empirical evidence in new Australian guidelines and in [your] editorial. The evidence of medium-term benefit from hormonal treatment and puberty blockers is based on weak follow-up studies. The guideline does not consider longer-term effects, including the difficult issue of detransition. Patients need high-quality research into the benefits and harms of all psychological, medical, and surgical treatments, as well as so-called wait-and-see strategies”.
August 2019, The Lancet Child & Adolescent Health journal | In a profile interview, RCH clinic director Dr Telfer says: “One of the things that has been really important for me and my career is learning to be publicly criticised. When you work in trans health, you upset people by doing the right thing. I knew that [the 2018 RCH treatment guideline] might be controversial because of the changes we made from the previous guidelines, but that was the whole point—to make changes so that the guidelines were clinically relevant”.
June 2020, The GenderGP Podcast, Dr Helen Webberley hosts an interview with Dr Telfer | Dr Webberley says: “We were really delighted when you produced the Australian Standards of Care in 2018. The world is crying out for documents and guidelines like that … I think [the RCH guideline] gives permission to those people and clinicians who have that gut feeling that this is the right thing to do, but nothing to back it up with and that’s what was missing, wasn’t it? … The first thing that I do, when anything like [a guideline] comes out, is I scan it. And so, I say, please don’t use the word 16 [as the minimum age for irreversible cross-sex hormones] … It just shouldn’t be in there. And you know, why does anyone have to wait until 16 to have their life progress?” [In April 2022, a UK medical practitioner’s tribunal reportedly found that Dr Webberley, founder of the GenderGP online clinic, had failed to provide adequate follow-up care to a 12-year-old child who was prescribed testosterone. The tribunal did not make an adverse finding on cross-sex hormones being given to a child that young, and said Dr Webberley might have been seen as a clinician “at the vanguard” of trans health care. See the account of GenderGP here.]
December 2020, Australian parliamentary inquiry into media diversity | In a submission, Dr Telfer says the RCH treatment guideline is “accepted as the current gold standard care for Australia and is used as such across the country”.
The gender guild’s guideline
AusPATH, the hybrid gender clinicians’ group and trans activist lobby, has been a staunch defender of the RCH guideline.
In May 2021, AusPATH tried to cancel media coverage of an internationally significant research paper which referred to the gender-affirming approach as “the dominant sociopolitical discourse”. The paper, with child and adolescent psychiatrist Dr Kasia Kozlowska as lead author, noted the pressure on clinicians to enable “conveyor belt” medicalisation at the expense of “ethical, reflective practice in mental health”.
“It appeared to us that a large subgroup of children [at the Children’s Hospital Westmead gender clinic in Sydney, Australia] equated affirmation with medical intervention and appeared to believe that their distress would be completely alleviated if they pursued the pathway of medical treatment,” the study said.
After the medical news website, Australian Doctor, published an article reporting the Kozlowska study, AusPATH president Dr Fiona Bisshop and vice-president Teddy Cook wrote to the editor requesting that the coverage be taken down, that Australian Doctor “issue a public apology and offer AusPATH a guest editorial”.
AusPATH’s email argued that the Kozlowska research “fits with misleading claims of gender diversity being something other than a very normal variation in human experience”.
AusPATH protested that the RCH treatment guideline had “largely been ignored” in the Westmead children’s hospital research, and that “none of the authors” were members of AusPATH.
The editor of Australian Doctor published AusPATH’s email of complaint, and said that after a review he had “found no reason” to take down the article reporting the Kozlowska research.
My news reports in The Australian newspaper, covering the period 2019-21, include the following fact and comment on the RCH guideline —
The state of Victoria’s then health minister, Jenny Mikakos, described the guideline as “national standards” ensuring “that children who are treated at gender clinics are protected by the most stringent safety standards”
National guidelines usually have authors from multiple centres of expertise, whereas the RCH guideline’s four authors were all from RCH
Health professional bodies covering the key gender clinic disciplines of psychiatry, clinical psychology and endocrinology said they were not formally consulted about the guideline
In small print acknowledgments, the RCH guideline thanks clinicians elsewhere in Australia for “consultation and feedback” and notes the “significant contribution” of trans people and trans lobby groups
Dr Telfer’s hospital defended the guideline, saying it had been “peer reviewed at the highest level, published in the Medical Journal of Australia and adopted by healthcare providers across Australia and the globe”
The MJA version of the guideline says: “The scarcity of high quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations”
Standards issued by Australia’s National Health and Medical Research Council urge those developing guidelines to “grade the strength” of the evidence for each recommendation
The RCH guideline was considered for inclusion in the NHMRC’s online portal Australian Clinical Practice Guidelines but did not qualify. An NHMRC spokeswoman said: “At the screening stage it was determined that the guideline did not include a funding statement, an evidence base for the recommendations or information about conflict of interest, and that it would not meet the portal selection criteria, so a full assessment was not carried out”
The RCH document does not carry the imprimatur of the NHMRC as an “approved guideline”, a status meant to signal that “a guideline is of high quality, is based on the best available scientific evidence, and has been developed to rigorous standards”
The guideline says that “withholding of gender-affirming treatment is not considered a neutral option” and suggests this may increase suicide risk. It cites a 2017 study of “trans young people” reporting that almost half had attempted suicide. This was an anonymous, online, self-report survey with a non-representative “convenience sample”, meaning there is no firm basis for extrapolating its findings to trans-identifying youth generally
The guideline advises that “psychiatric morbidities such as depression, anxiety and psychosis [should] not necessarily prevent” medicalised gender change, although the clinical decisions might be more complex
The guideline claims that “chest reconstructive surgery” [mastectomy] is regularly performed across the world in countries where the age of majority for medical procedures is 16 years”
It says genital surgery under 18 is “a relatively uncommon practice internationally” and advises this be left until adulthood because of its risks
In 2019, following media and professional scrutiny of the RCH guideline, the Royal Australian and New Zealand College of Psychiatry quietly removed its specific endorsement of the guideline from its LGBTIQ+ mental health policy. When I asked about this at the time, the college said it would review its policy stance and have a closer look at “the evidence behind the recommendations in the RCH document”
In 2021, the RANZCP announced a new, more cautious and detailed policy on gender dysphoria, noting the “paucity” of quality evidence on the outcomes of gender-affirming hormonal drug treatments and surgery such as mastectomy. The college pointed out that both “evidence and professional opinion is divided” on whether the affirmative approach should be used with children. The new policy reminded psychiatrists of the changes in identity and brain development that come with childhood and adolescence, insisting that judgments about the capacity of minors to consent to treatment should be clearly documented. The endorsement of the RCH guideline was not restored, with the college simply noting the RCH document in a footnote as one of several guidelines and position statements
Note: GNC does not dispute that gender-affirming clinicians believe their interventions are of benefit to vulnerable patients in distress. In a rare public statement in 2019, RCH said its gender clinic treatment was based on the “best available medical evidence”, in line with “international best practice”, and followed “strict clinical governance standards”.
Researchers associated with the clinic have acknowledged “an urgent need for more evidence” to inform gender dysphoria care and published an outline of a long-term outcomes study, Trans20 (although it appears to lack a comparison group to clarify the effect of the clinic’s gender-affirming treatment approach).
GNC sought comment from RCH; the hospital’s research partner, the Murdoch Children’s Research Institute; AusPATH; Dr Telfer; Dr Pang; Dr Bisshop; and Dr Kozlowska.