The Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents

The Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents are available at https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf. The following are quotes direct from the Guidelines and are the highlights for me:

“The Australian Standards of Care and Treatment Guidelines (ASOCTG) aim to maximise quality care provision to trans and gender diverse children and adolescents across Australia, whilst recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with professionals working with the trans and gender diverse population across Australia and New Zealand from multiple disciplines, trans and gender diverse support organisations, as well as trans children and adolescents and their families. They have been endorsed by the Australian and New Zealand Professional Association for Transgender Health (ANZPATH), the peak organisation in the region actively promoting communication and collaboration amongst professionals of all disciplines involved in the healthcare, rights and wellbeing of people who identify as trans or gender diverse…

Serious psychiatric morbidity is seen in children and adolescents. A study of the mental health of trans young people living in Australia found very high rates of ever being diagnosed with depression (74.6%), anxiety (72.2%), post-traumatic stress disorder (25.1%), a personality disorder (20.1%), psychosis (16.2%) or an eating disorder (22.7%). Furthermore 79.7% reported ever self-harming and 48.1% ever attempting suicide…

It is clear that further research is warranted across all domains of care for trans and gender diverse children and adolescents, the findings of which are likely to influence future recommendations…

Every child or adolescent who presents with concerns regarding their gender will have a unique clinical presentation and their own individual needs. The options for intervention that are appropriate for one person might not be helpful for another… Consistent with the above, decision making should be driven by the child or adolescent wherever possible, and this applies to options regarding not only medical intervention but also social transition…”

If I was a parent of a child who more or less told me that they have gender dysphoria, my first reaction would be anything but affirmation. I’d certainly ask gently critical questions to cautiously compare our childhood experiences, at least the child would feel listened to irrespective of affirmation. Then, I’d ensure they go see an even-handed psychologist (or two) who’ll take these Guidelines seriously.

“Autism Spectrum Disorder (ASD) has been demonstrated to be associated with gender diversity, and many children presenting to specialist gender services have co-existing ASD. Clinical guidelines for the management of co-existing ASD and gender dysphoria have recently been developed. For some children, a formal diagnosis of ASD can be helpful for their family and teachers in understanding their social interactions and behaviour and to find strategies to manage the difficulties they encounter.

When a child’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, or learning or behavioural difficulties, a more intensive approach with input from a mental health clinician will be required. This form of psychological support should be undertaken by a skilled mental health clinician with expertise in child cognitive and emotional development as well as child psychopathology, and experience in working with children with gender diversity and gender dysphoria. This support requires an understanding of the child and their family through a comprehensive exploration of the child’s developmental history, gender identity, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as immediate and extended family support, in a safe and therapeutic environment…

The optimal model of care for trans and gender diverse adolescents who present to services involves a coordinated, multidisciplinary team approach. This may include clinicians with expertise in the disciplines of child and adolescent psychiatry, paediatrics, adolescent medicine, paediatric endocrinology, clinical psychology, gynaecology, andrology, fertility services, speech therapy, general practice and nursing. It is unrealistic that all trans and gender diverse adolescents in Australia will be able to directly access comprehensive specialist paediatric services, especially with these specialist disciplines co-located within a public health service. Provision of a multidisciplinary team approach with coordination of care from general practitioners, private specialist practitioners and community based clinicians can be an effective alternative in ensuring best practice and accessibility to medical intervention…

Providing psychological care to trans and gender diverse adolescents requires a comprehensive exploration of the adolescent’s early developmental history, history of gender identity development and expression, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as immediate and extended family support. For example, many adolescents have experienced difficulties such as family rejection, bullying by peers, discrimination and occasionally physical assaults or other forms of abuse perpetrated against them in relation to their gender identity, and it is important to assess for this…

Sometimes, an adolescent’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties, or risk issues. In such cases, more intensive mental health input may be required from a skilled mental health clinician who not only has expertise in the cognitive and emotional development of young people and adolescent psychopathology, but also has experience in working with adolescents with gender diversity and gender dysphoria in a safe and therapeutic environment…”

Another reason to expect the psychologist to take a cautious approach, which may include “watchful waiting” if deemed appropriate. It’s not that I blanketly oppose “watchful waiting”, I just don’t think it should be the default. I think all options should be looked at with an even hand. Notice how the following addresses Rapid Onset Gender Dysphoria concerns. I think these are really good Guidelines for managing trans children (the UK can learn from the Australian experience), and if you have suggestions on how it should be improved without taking a black-and-white approach, I’m all ears:

“Managing distress during the assessment process can be difficult for adolescents and significant pressure is often experienced by clinicians from an adolescent who is certain of their need for treatment. This is often exacerbated by long waiting times to see clinicians who can provide treatment for gender dysphoria. Working with the adolescent to manage their expectations about progress and their distress is a necessity. Occasionally, counselling those who consider or do obtain hormone treatment from non-medical sources (e.g. online, via friends) on the risks of doing so should be undertaken whilst providing ongoing support and care to reduce vulnerability and risk…

An increased prevalence of disordered eating behaviours exists in trans and gender diverse adolescents, possibly due to a desire to adhere to the perceived ideals of one’s experienced gender. Unsafe weight management behaviours such as dietary fasting, diet pill and laxative use are elevated in trans young people, with use of non-prescription steroids also being higher in trans adolescents when compared to their cisgender peers. It is therefore important that the assessment of adolescents with gender dysphoria includes consideration of the possibility of co-existing eating disorders. It has been suggested that addressing an adolescent’s gender dysphoria may improve disordered eating behaviours. Other psychiatric comorbidities such as depression, anxiety and psychosis may also increase the complexity associated with treatment and intervention decisions but should not necessarily prevent medical transition in adolescents with gender dysphoria…”

Pronouns: who/cares | Omnivert | TransCatholic Liberal Arts student @notredameaus | @AUMallard contributor | all opinions expressed here are my own