A LANDMARK legal decision in November 2017 dramatically changed the landscape in the medical treatment of transgender and gender diverse (TGD) children in Australia. The judgement, handed down from the Family Court, ruled that TGD teenagers seeking gender-affirming hormone treatment no longer need authorisation from the Court, as long as their parents and treating doctors give their permission. The decision has been seen as sign that things are finally starting to move in the right direction in the recognition of TGD issues in Australia.

Now, hot on the heels of that breakthrough, we have the first-ever Australian guidelines for the medical care and treatment of TGD children, a summary of which is published by the MJA. The guidelines are endorsed by the Australian and New Zealand Professional Association for Transgender Health.

The guideline authors say that with supportive, gender-affirming care during childhood and adolescence, major harms can be avoided and the mental health and wellbeing outcomes of TGD children substantially improved. It offers recommendations for the psychological support of TGD children both before and after the onset of puberty, as well as best practice around such issues as puberty suppression treatment, fertility counselling, gender-affirming hormone treatment using oestrogen and testosterone, and surgical interventions for TGD adolescents.

Lead author Associate Professor Michelle Telfer, who is Director of the Gender Service at the Royal Children’s Hospital Melbourne, says that of the two international guidelines already in existence, one is out of date and the other, from the Endocrine Society, is very detailed in terms of endocrine management but doesn’t delve into the more general aspects of care.

“We wanted to have a guideline available that was really relevant to our clinical practice, and none of the others do that,” she told MJA InSight in an exclusive podcast.

Dr Telfer says that the best estimate of the number of transgender children in the population comes from a 2014 New Zealand study of over 8000 high school students, of whom 1.2% identified themselves as being transgender, with a further 2.5% saying they were unsure of their gender.

What is certain is that the number of children presenting to doctors with questions about their gender has increased substantially over the past decade.

“We had our first referral at the Royal Children’s Hospital in Melbourne in 2003, and until 2007 we only had three referrals in total. But last year we had 253 referrals within 12 months and in 2018 we’re heading towards 300.”

Dr Telfer puts that down to the increased visibility and acceptance of transgender people, and an environment where people are much more comfortable talking about their experience of gender than in previous generations. She says that her clinic has seen children as young as 3 years, brought in by parents who are unsure what to do when their child has expressed their thoughts about their gender.

“People say, how could they know when they’re that young? But if you ask any 3-year-old if they’re a boy or a girl, they’ll tell you in no uncertain terms. We have 2- or 3-year-olds who verbalise very clearly how they feel about their gender, and we listen. We don’t necessarily intervene at that age, but what is very clear from the research that’s coming out both in Australia and internationally is if you support the child to express themselves and be who they are, their long term mental health outcomes are very good and actually equivalent to the general population.”

Indeed, one of the key messages from recent research in young transgender people is the high cost they pay in terms of mental health when they are not adequately supported. A study of 859 young transgender Australians published last year found that 80% had engaged at least once in self harm and, shockingly, almost half had attempted suicide.

One of the co-authors of that study is psychologist Sam Winter, an Associate Professor at the School of Public Health at Curtin University and a board member of the World Professional Association for Transgender Health.

Dr Winter, who welcomes the publication of the new guidelines, says that one of the challenges for young transgender people navigating their way through the medical world is that the GPs, who are often the first port of call, don’t necessarily feel up to the task.

“Doctors often feel they’re ill-equipped and that they don’t understand the nature of what these kids are going through. A lot of GPs are perhaps unduly anxious and scared of working with these patients. We have such a history of regarding transgender people as this very specialised group and that we need to refer them on, as quickly as possible. That’s a mindset family practitioners need to discard. These are kids they’re going to meet, and they should learn to be comfortable with them and their families.”

He says the guiding principle is that TGD children need to be recognised as simply growing up differently, and that this is something that should be supported, rather than problematised.

“One should be affirmative, respectful, treat the child with dignity and use the pronouns that the child prefers. Parents and doctors should realise that if they don’t support their kid and allow them the space to explore who they are, they could end up depressed, anxious and even suicidal, because we know that’s what happens when these children aren’t supported.”

Dr Winter says that there are still plenty of doctors who take the view that these children have a disorder, rather than simply being different.

“Transgender health has not been taught in our medical schools and is still not taught. There’s a real task of education, particularly for GPs who tend to be the first point of contact. Doctors need to have a basic understanding that what they’re dealing with in TGD kids is diversity, not a disorder.”


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33 thoughts on “New guidelines for managing trans and gender diverse children

  1. Peter (Melbourne GP) says:

    Of children who undergo gender re-alignment surgery:
    20% wish to reverse the choice in adulthood.
    41% attempt suicide.
    61% suffer mental illness.

    And lest anyone think I’m biased, here’s an article summarising these findings from the lefty newspaper the Guardian.

    So for MJA Insight to state that the decision to take the decision out of parent’s hands and into the hands of a handful of agenda-driven doctors, as “seen as sign that things are finally starting to move in the right direction in the recognition of TGD issues in Australia” is beyond disgusting. And I seriously doubt the vast majority of doctors would agree with you.

  2. Peter (Melbourne GP) says:

    Sorry, I misread the first paragrap. Had nothing to do with parent’s rights. But the statistics and the agenda remain the same.

  3. Anonymous says:

    Is gender realignment surgery actually reversible?

  4. Anita Watts says:

    The article Peter quotes is 14 years old. Perhaps he’d be interested in reading a more recent article.

    Or, if he prefers the Guardian, he could read this one

  5. Dr Fiona Cameron says:

    This is political propaganda from the trans lobby, not proper medical advice. It is full of unproven assertions, non scientific terminology and does not belong in MJA.

  6. Dr John I. Garrity. FRCOG. FRANZCOG. says:

    I would strongly recommend that all members of the AMA and especially Professor Michelle Telfer, become aware of the views of the American College of Paediatricians on Gender Dysphoria in Children. Of course, 20,000 plus American Paediatricians may be incorrect in their views on this subject.

    I would draw attention to 2 recent publications by the American College of Paediatricians:

    1. Normalizing Gender Dysphoria is Dangerous and Unethical. August 3 2016. Media contact – Michelle
    Cretella. MD, FCP. President of the American College of Paediatricians

    2. Gender Dysphoria in Children. June 2017. Primary author – Michelle Cretella

    Dr Cretella, in the second article, has a lengthy and detailed reference list that Professor Telfer of Melbourne should pay careful attention to before she makes any further public announcements on this subject. After delivering more than 10,000 infants I have more than a passing interest in the well being of children.

  7. Andrew Nielsen says:

    The pendulum is already getting ready for the return journey. It will mostly be driven by who wish that they did not have irreversible treatment.

  8. Anonymous says:

    gender is only social concept, therefore disease is not possible , any “gender dysphoria” is socially induced so treat society not the child.(other than the rare genetic males and females who are genetically mixed or have errors in hormone mechanisms)

  9. Anonymous says:

    Wow, amazing levels of bigotry being expressed here. What a hateful bunch of so-called doctors. God help the transgendered child who asks you for help.

  10. D Spearritt says:

    Please be aware that the American College of Pediatricians Lead by Michelle Cretalla is not the peak body of paediatricians in the USA. It is a small conservative group.

    The real group is the American Academy of Pediatrics who support affirming care for transgender children and adolescents.

  11. Anonymous says:

    So sad that confused children are to be medically sacrificed to a socio-political fashion.

  12. Anonymous says:

    American College of Paediatricians is also (according to Position Statements listed on their own website) against cohabitation as it negatively impacts on the chances of future marriage; supports the use of corporal punishment on children, believe same-sex attraction is “preventable and changeable” and believes in restricting access to emergency contraception and abortion.

    The Society for Adolescent Health and Medicine Executive Committee (who publish a little know periodical called Journal of Adolescent Health) responded to some of Dr Cretella’s positions on gender dysphoria here: https://www.adolescenthealth.org/SAHM-News/SAHM-Responds-to-Dr-Michelle-Cretella.aspx

    I also note the response linking the American Academy of Pediatrics position.

    I also note the bigotry. Sad days, but hardly surprising.

  13. Peter (Melbourne GP) says:

    Anonymous, one could express themselves in like manner. “What a harmful doctor. God help the child who asks for your advice about their gender identification issues, they might not have a way to undo what you push them into doing.”

    I refuse to refer any child for gender re-aligning surgery. Honestly, if one can speak plainly and not be accused of bigotry, any more than I would refer a child for growth hormone therapy if they identify as being tall.

    It is very clear to anyone who has perused the literature in this field that there are TWO COMPLETELY OPPOSED lines of research, one showing clear harm and one showing clear benefit. One is left to decide which side is the biased one. It would help to take a look at the study authors, those showing benefit tend to me produced and funded by transgender/LGBTI backed organisations.

    The results speak for themselves. Why are almost half of children who have gender reassignment surgery committing suicide? I thought it was being pushed as a means to stop suicide happening in this group?

  14. Dr Kate Toyer BVSc MANZCVS(Surg) says:

    And you lot wonder why we attempt suicide and have mental health issues when even doctors reference know anti LGBTI groups like the American pretend organisation.

    These guidelines are an awesome relief and benefit for many families. Well done to all involved from a trans woman who wishes that we had this understanding when I was a child.

  15. Peter (Melbourne GP) says:

    Dear Anita Watts,

    OK so your research is more recent, and in the Guardian! Very clever.

    Look at the entire body of literature, and you can find a handful of studies proving both sides of the situation. If one study says very bad, and one says very good, one must wonder if there is some sort of bias, no? 10 years does not inversely change the outcome of a study. It rather demonstrates the rise of a body of opinion pushing an agenda, complete with people yelling ‘bigot’ if you challenge the dogma. Like the studies showing two fathers or two mothers can do the job of a married couple in childhood outcomes. Real life experience demonstrates otherwise. Studies can be used to demonstrate any thing in the world of psycho babble.

  16. Peter (Melbourne GP) says:

    With all respect Dr. Kate Toyer, 41% commit suicide and 60% have serious mental health issues AFTER having realignment surgery, not before. Any treatment that results in that level of harm should not even be considered.

  17. Lyndal (Psych Reg) says:

    Peter, would it not shock you that people with mental health health issues still can have mental health issues and crises even after they are on treatment? This is the same thing.
    If I was a trans kid who had grown up in a world where my identity has been invalidated every day by adults such as yourself and society at large, is it any wonder I might still feel I shouldn’t belong on earth even if my body now felt more comfortable to live in?

  18. Ricki Coughlan says:

    Thanks and congratulations to Dr Telfer and her associates for producing these excellent guidelines based on peer reviewed research and world’s best practices. Her work will be welcomed by all families with transgender children and all who value continuing efforts to better understand and assist those who seek help in this regard.

  19. Ricki Coughlan says:

    Dr John I. Garrity I would draw your attention to the fact the American College of Paediatricians is well documented as a fringe hate group which draws upon bogus, discredited “research” and its own “announcements” as source information. A simple search of the internet reveals this.

    I am somewhat surprised that you were able to find all of the bogus material you have alluded to in your comments and yet none of the peer reviewed research indicating the excellent outcomes from affirming and supporting transgender children and youth, the excellent outcomes following the use of puberty blockers and stage 2 hormone intervention and gender confirmation surgeries. Indeed the very recent and massively publicised research which clearly indicates a biological basis for transgenderism seems to have completely eluded your browser . . . astounding!

  20. Peter (Melbourne GP). says:

    Lyndal (Psych Reg),

    Your suggestion that transgender children commit suicide because “adults such as [myself]” invalidate their identity is clever, but I wonder how it would hold it to further scrutiny. There is zero evidence that discrimination of any sort is a significant risk factor for suicide. (Yes, it is a risk factor, but not one of the most significant ones).

    1. The group with the highest successful suicide rate in Australia?
    White men.

    2. The suicide rate amongst blacks in America?
    Less than whites, who suffer far less discrimination.

    3. Suicide attempt rates amongst transgender children who HAVE NOT come out publicly as transgender?
    Almost the same (few % short) of the 41% quoted.

    4. Riskiest general risk factor for suicide apart from past attempts?
    A mental illness. (Not societal non-acceptance of a mental illness).

    Can you propose any alternative meaning to these facts?

  21. Anonymous says:

    Very worrying that a doctor is misinformed enough to keep stating that idiotic 41% suicide rate, that is clearly untrue. https://medium.com/@notCursedE/dear-benshapiro-re-trans-suicides-be483052d97f this might help you out.

  22. Anonymous says:

    Ricki Coughlan, you refer to short term studies, nothing measuring reasonably long-term outcomes (in children who have this surgery).
    Ask a kid if they feel better after getting what they wanted, and you think they’ll say no?
    Try asking them 20 years later.

  23. Anonymous says:

    Peter … if you took the time to read the guidelines summary, and maybe even listen to the podcast, you’d be educated about the advice and processes that are actually recommended, instead of whatever misinformation you think they’re full of. In fact, I’m willing to bet the views of the naysayers here are based more on religious beliefs, whatever flavour they are, than on actual science.

  24. Peter (Melbourne GP) says:

    Anonymous, you state

    “Very worrying that a doctor is misinformed enough to keep stating that idiotic 41% suicide rate, that is clearly untrue.”

    Why is it untrue? Because you found a blog post attacking Ben Shapiro? Read the research yourself.


  25. Marcus says:

    #21. Nevertheless the attempted suicide rate is a focus of consternation.
    What I have not seen is the discussion on the higher rates of Borderline Personality Disorder in trans persons.
    One can delve into whether poor maternal attachment has a role is being trans, or whether a child exhibiting trans tendencies engenders poor maternal attachment, but there is a correlation nevertheless with BPD.
    BPD is independently associated with higher rates of attempted suicide, and being trans (and society’s response to that) may simply be epiphenomena.
    BPD patients are amongst the very hardest to treat in psychological medicine.
    Most who have had significant experience in the treatment of BPD would be wary of permanent genital reassignment surgery as a treatment to mitigate suicide attempts in this group.

  26. Zoe, Qld says:

    I would like to comment from personal experience as a GP and the mother of a transgender teenager. When our kid declared their transgender identity at the age of 12 I was devastated, not least because the feelings of loss I experienced challenged my own identity as a socially progressive person. My husband and I love and respect our kid deeply and we handled the situation by listening, asking open questions, and learning from them about the experience of being trans. Nothing in our own past experiences had prepared us for this. We needed to be sure that they were sure. When a trans kid or parent sits down in your office, please, use your training – listen, ask open questions, and don’t be too quick to judge. Families like ours really need these guidelines – well done.

  27. Anonymous says:

    It just doesn’t make sense. The differences between Men and Women are so meaningless today – in terms of roles in occupation, or sport, or anything I can think of – how can we accept that people will get so worked up about these differences that they are wanting to undertake serious medical and surgical treatments? What exactly do they ope to achieve? In fact the only real difference between a Man and a Women today – would be in very blunt terms – that a Man can produce sperm, father children and potentially die of prostate cancer, whereas a woman can fall pregnant and produce a baby. All other sub categories of gender /sex etc etc kind of miss the whole point of gender/sex – which is to reproduce. So why would anyone undergo gender reassignment whatever – when the one true difference – cannot be achieved? They are being sold a dud. The Emperor has no clothes.

    Psychiatrists can’t agree on this condition, how to classify it or how best to treat it. Why is gender dysphoria not just a severe form of borderline personality disorder? Why is it not classified as a delusional thought disorder.

    Why is no -one looking into the cause? Is this something environmental?

    Furthermore – why would anyone sign away their ability to reproduce? How can anyone under 18 consent for this?
    How can it be reconciled with “do no harm”?

    When did we start to think that surgical options were ok for psychiatric disorders ? Will we now offer gastric bypass surgery to patients with anorexia because they are distressed or threaten suicide if we don’t?

    Enjoy your delusional thinking if you will, but do not punish those of us who do not share it. I am very concerned that legal and political pressure will now come to bear that those of us who do not share this delusional thinking – and unless we embrace it will find ourselves excluded from public hospitals, or perhaps even practicing medicine. For instance iIf woman who takes hormones and grows a beard and calls herself a man comes to my emergency department with abdominal pain and bloating – and I ask to take a pregnancy test – will she be able to sue me? prosecute me for prejudice? Can she sue me because I don’t use the pronoun she wants? We cannot have lobby groups, lawyers etc getting us to re write medical fact.

  28. Cate Swannell says:

    EDITOR’S NOTE: Well, if there was ever an argument for blocking anonymous comments on this website, this thread and the one on sexual abuse have certainly provided the evidence for giving it a trial run. So here goes. For the next month, starting right now, if you can’t put your real name to your comment, it will be blocked. Time for the keyboard warriors to step out into the light. Thanks. Cate

  29. Ian Truscott says:

    I put a comment in, last night, using my name, & it seems to have been blocked.
    Was it because of the words I used to describe the surgery involved?
    Or because I gave this link, https://www.youtube.com/watch?v=OYvkiq8EEJc&t=2377s of a transgender person who regretted his decision?

  30. Peter (Melbourne GP) says:

    Cate, I don’t think anyone has posted anything bordering inappropriate. I think all sides have been able to have at least some sort of discussion. I’m all for blocking Anonymous posts if it helps avoid trolls, but why are you so upset about this discussion?

  31. Penny GP says:

    To all the haters commenting here:

    Trans people exist. Trans children exist. Maybe that doesn’t fit into your world view, but sorry that doesn’t make them disappear.

    There’s a firm body of evidence that they do better if they’re treated with respect rather than dismissal. While yes there’s some overlap with BPD and ASD, still in these groups in my experience they do better with respect rather than dismissal.

    What exactly do the naysayers suggest here exactly? Forced re-education? Denial of care? I’m not sure we actually have an alternative treatment with a better success rate. The history of conversion therapy shows a far far higher rate of bad outcomes than respect does.

    While some people regret transitioning, there’s far higher rates of regret for cosmetic surgery, and yet people requesting cosmetic surgery certainly aren’t afforded the same level of negativity.

    Please, give us a viable alternative with better outcomes and we’ll go for it.

  32. Peter (Melbourne GP) says:

    Penny GP says:

    “Trans people exist. Trans children exist.”

    “There’s a firm body of evidence that they do better if they’re treated with respect rather than dismissal.”

    “What exactly do the naysayers suggest here exactly? Forced re-education? Denial of care?”
    The question here is hormonal/surgical treatment vs supportive care without such treatment.
    And we are talking about children.

    “While some people regret transitioning, there’s far higher rates of regret for cosmetic surgery.”
    Cosmetic surgery is not offered to children.
    Cosmetic surgery does not change your gender. Rubbish comparison.

    “Please, give us a viable alternative with better outcomes and we’ll go for it.”
    Supporting them without cutting or hormone pumping/blocking.
    In a child.

    I hope these responses are reasonable Penny.

  33. Anonymous says:

    Thank you Raymond. I don’t have much skin in the game at the moment, but that article you shared had some great recommendations and put things in perspective with a good helping of common sense.

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