Australian doctors affirm trans children, and show why affirmation works: Trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community, and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life, such as the family’s general practitioner or school supports. Others need a skilled clinician working with the family, to help them support their child. Where there are other mental health problems, they should be treated together with GD.
Parents who do not support their child’s transition may make their mental health worse. “Do no harm” does not mean refusing gender-affirming treatment:
Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.
Social transition improves emotional functioning. It should be the child’s decision, and may be just at particular times or particular places. Social transition brings trans children’s depression, anxiety and self-worth to the same level as cis children’s. Doctors may need to be advocates, telling schools this is what the child needs. An endocrinologist should see the child before puberty starts.
Children referred in adolescence need different treatment. The child may have spent a long time coming to understand their gender dysphoria, and considering how to explain it to parents, so will want immediate support and medical help, but a parent might see this as sudden, and have difficulty adjusting. The child needs 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.
Once there is significant breast growth and menstruation in a trans boy, puberty suppression is not recommended. Gender dysphoria around menstruation can be reduced with norethisterone. Testosterone in trans boys may produce irreversible facial and body hair growth and scalp hair loss. Deepening of the voice is irreversible. Clitoral enlargement and vaginal atrophy may be reversible, but this is unknown.
Oestrogen in trans girls will reduce muscle mass and strength, soften skin, and decrease libido and spontaneous erections. These effects are probably reversible. Breast growth is irreversible. The testicles will shrink, and sperm production decrease: it is unknown if these effects are reversible.
Teenagers vary in their maturity, and ability to make decisions with complex risks and benefits. However delaying hormone treatment in trans girls means increased masculinisation of face and body, and suppressing puberty without starting stage 2 treatment (gender-affirming hormones) can weaken bones. Refusing treatment reduces an adolescent’s sense of their own autonomy and agency.
GPs should give an initial assessment, including of the family support and functioning, and advise on the effect of treatment on sexuality, sexual pleasure, and fertility.
A trans boy may have chest masculinisation surgery as young as 16. There should be a joint decision with child, parents and clinicians coming to consensus, taking account of the child’s maturity. However the guidelines advise delaying genital surgery until adulthood, because it will make the patient sterile, and may reduce sexual pleasure and interest.
The New Zealand Adolescent Health Survey suggested that 1.2% of adolescents identify as transgender. The guidelines suggest that this means referrals will continue to rise. Only an atmosphere of support and acceptance will enable a child to make a proper decision.