Butchers

The treatment of gender dysphoria in children and adolescents remains contentious.
The doctors say a number of older patients treated under the current model of gender affirmation have gone public with their regrets about irreversible interventions.
This model, championed by clinicians at the Gender Service clinic at the Royal Children’s Hospital in Melbourne, emphasises the “felt sense of gender” and takes the view that decision-making around treatment should be driven by the child or adolescent whenever possible.
The Sydney doctors, including paediatric endocrinologist Professor Geoffrey Ambler and psychiatrist Dr Kasia Kozlowska, said many children equated gender affirmation with medical intervention and believed their distress “would be completely alleviated if they pursued the pathway of medical treatment”.
Both the patients and their families arrived at the clinic with strongly entrenched beliefs, and the doctors’ efforts to discuss psychological, social or family issues “fell on deaf ears”.
“We recognised the emergence of this ‘conveyor belt’ or ‘tick the box’ mentality — the medical model for treating gender dysphoria, stripped bare of holistic (biopsychosocial) care — as being driven by the misguided belief that affirmation of gender dysphoria equates to a medical intervention pathway,” they wrote.
They added that many children “did not have the cognitive, psychological or emotional capacity to understand the decisions they were making”.
“It became apparent to us that children in early and mid-adolescence found it difficult to consider issues concerning parenthood and fertility, along with the impact of medical interventions on their future capacity to bear children, because the issues were not yet pertinent to them at their present developmental stage,” they wrote.
They added: “Lost were our efforts to highlight the many different pathways in which gender variation could be expressed, to explain potential adverse effects of medical treatment … and to highlight the importance of ongoing psychotherapy.”
Writing in the journal Human Systems: Therapy, Culture and Attachments, the team presented data from 79 children (median age 13) and their families referred to the hospital’s gender service clinic between December 2013 and November 2018.
Among the participants — 33 biological males and 46 biological females — one in 10 had attempted suicide, 15% had self-harmed and almost half reported suicidal ideation.
High rates of comorbid mental health disorders were also reported, including anxiety (63%), depression (62%), behavioural disorders (35%) and autism (14%).
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Furthermore, most reported one or more “adverse childhood experiences”, such as family conflict; maltreatment in the form of sexual, physical or emotional abuse; exposure to domestic violence; parental mental illness; loss by separation; and bullying.
More than half of the children (54%) said they had one or more family members who “were rejecting/ambivalent or had not been told about the child’s dysphoria in order to avoid conflict or rejection”.
“[These experiences] reflect a longstanding history of relational stress and a chronic disruption of what are normally comfortable and nurturing attachments.”
But the motivation to engage in long-term therapy designed to the broad range of psychological, family and trauma issues was generally low.
Another challenging aspect of their work was the increased pressure to prescribe cross-sex hormones to children aged 16 and over following a 2017 ruling by the Family Court of Australia.
The ruling essentially removed the requirement for court approval to access stage 2 treatment — cross-sex hormones — and put this responsibility into the hands of doctors.
“In the wake of [this] … some families presented to the clinic with the expectation that a child nearing the age of 16 could attend the gender service, see the mental health team for a one-off consultation, collect a diagnosis of gender dysphoria, and move to another service to obtain stage 2 treatment … with no engagement in a therapeutic process.”