more_vert
WITH a growing number of children and adolescents seeking treatment for gender dysphoria in Australia, experts have highlighted the important role GPs play in early intervention.
An “Ethics and law” article published online by the MJA highlights the clinical, legal and ethical issues associated with the rise in applications to the Family Court of Australia seeking authorisation to start hormone therapy treatment in young people diagnosed with gender dysphoria. (1)
The authors described gender dysphoria as a serious condition, in which a child’s subjectively felt identity and gender were not congruent with his or her biological sex, “causing clinically significant distress or impairment in social functioning or other important areas of functioning”.
Professor Louise Newman, director of the Monash University Centre for Developmental Psychiatry and Psychology and former president of the Royal Australian and New Zealand College of Psychiatrists, told MJA InSight the increase in applications regarding gender dysphoria to the Family Court reflected “a very sophisticated level of awareness among children and adolescents”.
She believed this was due to decreasing social stigma surrounding the condition, the inclusion of transgender issues in school education, and the access young people have to online information and networks.
The authors of the MJA article wrote that, in a significant development, courts in Australia had officially drawn a distinction between stages 1 and 2 of treatment — the provision of puberty blocking medication, and cross-sex hormone treatment.
Parents could now consent to the first stage of hormonal treatment on behalf of their children because it was reversible. However, stage 2 treatment still required court authorisation due to its irreversible effects and the risk of making a wrong decision about a child’s present or future capacity for consent.
“In addition, when a minor possesses sufficient understanding of the nature and consequences of stage 2 treatment, she or he has legal capacity to consent to that aspect of treatment, but the finding of competency must be made by a court”, the authors wrote.
The authors said that the new legal landscape in Australia for gender dysphoria treatment was of importance to both practitioner and patient, and that “increased awareness of treatment possibilities, the benefits of early intervention, and of the legal framework, would be beneficial”.
Professor Newman believed GPs played a vital role in early intervention as they were the first point of call for patients seeking assistance, and made the decision as to whether a child should be referred to a specialist.
She said before any decision is made, it was important that GPs first undertake a careful and thorough assessment of the child, which should take place over the course of several sessions.
“GPs have to explore the child’s feelings about their gender identity. Does it affect their functioning? Are they in distress? Is it impacting their peer relationships? How do they feel about going to school?”
Professor Newman said to assist GPs in deciding whether a child should be referred to a specialist, the feelings of the patient’s family must also be considered.
Dr Michelle Telfer, paediatrician for the Gender Dysphoria Service at the Royal Children’s Hospital, Melbourne, told MJA InSight that, in her experience, both parents usually supported their child receiving treatment “but sometimes there is one parent who is less supportive than the other”.
However, she said it was paramount to the child’s welfare that a GP still refer these families to a specialist clinic.
“Our centre provides education and information to the whole family, and tries to assist parents in making decisions. It’s very important for parents to understand the risks of not supporting their child’s decision, such as depression and possibly suicide.”
Dr Telfer said that once treatment was consented to, the medical and psychiatric processes that patients and families underwent were highly complex and would be overseen by “a multidisciplinary team of physicians, psychiatrists, gynaecologists and endocrinologists”.
She said that with the additional legal costs involved with seeking court authorisation for stage 2 treatment, it was best if GPs referred patients to a public hospital environment as “cross-hormone treatment would otherwise cost around $5000 per patient per year”.
Dr Telfer believed, in most cases, GPs were very open to referring children to specialist care for gender dysphoria, which highlighted the benefit of keeping doctors informed and up-to-date on clinical and legal developments.
“When GPs are reluctant to refer a child, it’s mainly due to not being aware of treatment options rather than any personal opposition.”
1. MJA 2015; Online 26 January
(Photo: martinedoucet / iStock)
Virtually all adult transitioners grew up in an era when we did not have access to the information. The quality of the information at the time was poor at best and unless you were running around in a dress and singing in bars you need not bother to apply. Children, adolescents and their parents have much greater opportunity to transition without the long-term anguish many of us adult transitioners had to put up with.
Social education and community awareness of transsexuals in the past 2-3 years has accelerated at a exponential rate. The nonsense that the religous right spews is slowly being silenced with calm and rational discourse. You know they are grasping at straws when the discourse revolves aound toilets and change rooms.
Universal access to appropriate clinical care is vital. Transition-related care is not cosmetic. I would argue as per the WPATH SOC, that it is medically indicated interventions to relieve the dysphoria that the person is experiencing. Being able to present in your affirmed gender and be recognised as your affirmed gender is vital. If interventions such as facial hair removal is required to achieve that then it should be covered. As with other areas of health & wellbeing early interevtion is best practice and reduces overall costs.
I agree with Rosie that early specialist referral is essential particularly when the GP is unfamiliar with the condition. I have been through this process as a the parent of a transgender child – we went to our wonderful GP (also a colleague). Despite being wonderful in general, and not (I think) transphobic in any nasty way, he managed to say some very insensitive things which devastated my child and fractured that therapeutic relationship irreparably. This meant that not only was there a need for a battery of specialists but also a new GP. Such a pity to lose that continuity of primary care.
FWIW the problem comments were things like “it’s just a part of your underlying depression” “don’t worry, it’s just a phase that will pass” “being transgender is very trendy right now” “I’ve had patients with these issues and if they don’t get over it their adult lives are very tragic”. Nothing malicious, but plenty that seriously offended and insulted patient (and family!)
The sad death of Leelah Alcorn is a stimulus to trans people still in hiding from help to come forward and be embraced.
The article is responsible and balanced. As a ‘prescriber’ as opposed to a therapist and assessor I can stand on the sidelides and make comment without fear. I would assert that most GP’s have little or no understanding of gender dysphoria; so when they are confronted by the problem their ignorance may prompt them into denial or rejection. That will continue to be the sad situation until gender dysphoria gets on to the undergraduate curriculum, an observation that was perhaps emphasised by the invitation for me to speak at the students conference in Melbourne last year.
The advice <…..GPs played a vital role in early intervention as they were the first point of call for patients seeking assistance, and made the decision as to whether a child should be referred to a specialist. She said before any decision is made, it was important that GPs first undertake a careful and thorough assessment of the child, which should take place over the course of several sessions. “GPs have to explore the child’s feelings about their gender identity. Does it affect their functioning? Are they in distress? Is it impacting their peer relationships? How do they feel about going to school?”….> is I believe misplaced. In this situation it would be best for the GP to recognise, empathise and refer on promptly- that is assuming that the GP in question has had no special training. Psychiatric assessment is best undertaken on someone who has not been ‘contaminated’ by previous attempts at therapy.
Dr Rosie Jones