Rise in gender dysphoria cases

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

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