Introduction: The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while ...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 Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families.
Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre‐pubertal children and TGD adolescents, as well as discipline‐based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy.
Changes in management as a result of this statement: Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent's capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.
Recent referrals of transgender young people to specialist gender services worldwide have risen exponentially, resulting in wait times of 1-2 years. To manage this demand, we introduced an innovative ...First Assessment Single-Session Triage (FASST) clinic that provides information and support to young people and their families and triages them onto a secondary waitlist for subsequent multidisciplinary care. Although FASST has been shown to substantially reduce initial wait times, its clinical impact is unknown.
FASST was evaluated by analysis of clinical surveys and qualitative interviews. A total of 142 patients were surveyed before and after FASST, and comparison was made to a historical control group of 120 patients who did not receive FASST. In-depth interviews were also held with FASST attendees (
= 14) to explore experiences of FASST, and inductive content analysis was performed.
After FASST, there were improvements in depression (standardized mean difference SMD = -0.24; 95% confidence interval CI: -0.36 to -0.11;
< .001), anxiety (SMD = -0.14; 95% CI: -0.26 to -0.02;
= .025) and quality of life (SMD = .39; 95% CI: 0.23 to 0.56;
< .001). Compared with historical controls, those attending FASST showed reduced depression (SMD = -0.24; 95% CI: -0.50 to 0.01;
= .065) and anxiety (SMD = -0.31; 95% CI: -0.57 to -0.05;
= .021). FASST attendees qualitatively described an increased sense of agency, which was related to improved outlook, validation, sense of self, and confidence.
Given burgeoning waitlists of pediatric gender services worldwide, this study suggests FASST may prove a useful model of care elsewhere.
IntroductionTrans young people are at a higher risk of mental health difficulties such as depression, anxiety and suicidality than their cisgender peers, due in part to their experiences of minority ...stress. This protocol describes a feasibility trial and subsequent pilot randomised controlled trial (RCT) of a codesigned group cognitive–behavioural therapy intervention for trans young people, named Trans Adolescent Group ThErapy for Alleviating Minority stress (TAG TEAM).Methods and analysisTo evaluate TAG TEAM, we will conduct a feasibility trial followed by a pilot RCT with trans young people aged 14–16 years who have been referred to the Royal Children’s Hospital Gender Service in Melbourne, Australia. In the feasibility trial, we aim to enrol 32 participants who will be randomised at a 1:1 ratio to either in-person or online intervention arms. Participants will be assessed at baseline and post-treatment, with a nested qualitative evaluation post-treatment. Primary outcomes are the feasibility and acceptability of the intervention and the study design and associated procedures, including comparison of the in-person and online delivery modes. In the subsequent pilot RCT, we aim to enrol 64 participants who will be randomised at a 1:1 ratio to an intervention or waitlist control arm, with delivery mode determined by the feasibility trial. Participants will complete assessments at baseline, post-treatment and 3-month follow-up. Primary outcomes are the feasibility and acceptability of the RCT study design. In both the feasibility trial and pilot RCT, participants will complete assessments related to mood, anxiety, suicidality, quality of life, minority stress, family support and social transition. Quantitative data will be analysed using descriptive statistics. Qualitative data will be analysed using thematic and interpretive analysis.Ethics and disseminationThe Royal Children’s Hospital Human Research Ethics Committee has approved this study (#91162). Informed consent will be obtained in writing from all participants and a legal guardian. Findings will inform the development of a full-scale RCT to evaluate the efficacy of TAG TEAM and will be disseminated through conferences and peer-reviewed journals.Trial registration numberACTRN12623000302651, ACTRN12623000318684.
Abstract Purpose Cyberbullying perpetration (using communication technology to engage in bullying) is a recent phenomenon that has generated much concern. There are few prospective longitudinal ...studies of cyberbullying. The current article examines the individual, peer, family, and school risk factors for both cyber and traditional bullying (the latter is bullying that does not use technology) in adolescents. Methods This article draws on a rich data set from the International Youth Development Study, a longitudinal study of students in Victoria, Australia and Washington State, United States, which began in 2002. In this article, data from almost 700 Victorian students recruited in grade 5 are analyzed to examine grade 7 (aged 12–13 years) predictors of traditional and cyberbullying perpetration in grade 9 (aged 14–15 years). Results Fifteen per cent of students engaged in cyberbullying, 21% in traditional bullying, and 7% in both. There are similarities and important differences in the predictors of cyber and traditional bullying. In the fully adjusted model, only prior engagement in relational aggression (a covert form of bullying, such as spreading rumors about another student) predicted cyberbullying perpetration. For traditional bullying, previous relational aggression was also predictive, as was having been a victim and perpetrator of traditional bullying, family conflict, and academic failure. Conclusions The use of evidence-based bullying prevention programs is supported to reduce experiences of all forms of bullying perpetration (cyber, traditional, and relational aggression). In addition, for traditional bullying perpetration, addressing family conflict and student academic support are also important.
To better understand the clinical profile of patients attending a large Australian pediatric gender service. Retrospective clinical audit of patients seen at the Royal Children's Hospital Gender ...Service (RCHGS) over 10 years (2007-16).
The RCHGS: Australia's largest pediatric gender service.
Patients were eligible for inclusion if they had an appointment with the RCHGS between January 2007 - December 2016, and had either a self-reported gender which differed from what was presumed for them at birth or sought guidance regarding gender identity/expression.
Demographic/developmental history, clinical presentation including information about gender identity/dysphoria, comorbidities, self-harm, suicidal ideation, gender-affirming treatment, psychosocial functioning.
359 patients were first seen during the study period. Assigned females (54%) slightly outnumbered assigned males (46%), and presented at an older age (14.8 vs 12.4 years. Patients predominantly identified as transgender (87.2%) or non-binary (7.2%). Across the cohort, gender diversity was evident from a young age (median age 3), and symptoms of gender dysphoria were noted earlier in assigned males (median age 4) than assigned females (median age 11). Although 81% of patients met eligibility for GD, rates of hormonal treatment were much lower, with 29% of young people ≥10 years of age receiving puberty blocking treatment and 38% of adolescents ≥ 16 years of age receiving gender-affirming hormones (i.e. testosterone or estrogen). Many patients had mental health difficulties and/or neurodevelopment disorders, including major depressive disorder/low mood (51%), self-harm (25%), suicidal ideation (30%) and autism spectrum disorder (16%).
This audit illustrates the complex profile and needs of transgender and gender diverse children and adolescents presenting to specialist gender services. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1939221 .
Transgender and gender-diverse (TGD) children and adolescents may experience not only gender dysphoria but also depression and anxiety, all of which are likely to be associated with reduced quality ...of life (QOL). Despite this, little is known about QOL in this population.
To identify demographic, social, and clinical characteristics associated with reduced QOL in TGD children and adolescents; compare their QOL with age-matched population-based norms and that of young people with common mental health problems; and evaluate the association between gender dysphoria and QOL.
In this cohort study, baseline data were derived from questionnaires completed in a prospective cohort study (Trans20) of TGD children aged 6 to 12 years and adolescents aged 13 to 17 years first seen at the Royal Children's Hospital Gender Service (Melbourne, Australia) between February 2017 and February 2020.
The main outcome was QOL, measured using the Child Health Utility 9D instrument (CHU-9D). Data collection included demographic information, social factors (eg, bullying, lack of support, and social transition), and clinical characteristics (eg, gender identity, gender dysphoria, and mental health difficulties). Population norms and CHU-9D data for Australian youths with mental health diagnoses were derived from published literature.
The TGD cohort comprised 525 children and adolescents aged 6 to 17 years (median age, 14 years IQR, 12-16 years; 364 69.33% presumed female at birth). The mean (SD) CHU-9D score was 0.46 (0.26). Compared with population norms, TGD children (0.58 0.27 vs 0.81 0.16; P < .001) and adolescents (0.41 0.25 vs 0.80 0.14; P < .001) had significantly lower scores. Within the TGD cohort, mean (SD) scores were significantly lower in adolescents (0.41 0.24 vs 0.62 0.25; P < .001), those assigned female at birth (0.43 0.26 vs 0.55 0.25; P < .001), those reporting mental health problems (0.37 0.23 vs 0.57 0.25; P < .001) and physical health problems (0.41 0.26 vs 0.48 0.26; P = .04), and those who were bullied (0.38 0.24 vs 0.52 0.25; P < .001). Gender dysphoria alone was associated with a lower mean (SD) CHU-9D score (0.51 0.23) than that in control adolescents with serious mental health conditions such as depression (0.64 0.26) and anxiety (0.70 0.24) and was an independent factor associated with QOL.
In this cohort study of TGD children and adolescents in Australia, QOL was worse in this population than in age-matched, population-based peers. Quality of life associated with gender dysphoria was substantially worse than that seen in young people with common mental health conditions. These findings emphasize the risk of poor QOL among TGD young people and the need to better support them.
The promotion of optimism has been widely advocated for children and adolescents, but epidemiologic data to support this approach are scant.
This was a 3-wave longitudinal study of health and social ...development in younger adolescents from 3 Australian states. The 5634 student participants, initially aged 12 to 14 years, were assessed for optimistic thinking style, emotional problems, substance use, and antisocial behaviors.
Cross-sectional associations between optimism and each of the study outcomes were strongly protective but tended to differ according to gender in extent. In prospective analyses of the onset of new cases of each study outcome, protective associations were weaker. Those in the highest optimism quartile had risks for depressive symptoms that were reduced by almost half (odds ratio: 0.54 95% confidence interval: 0.42-0.70) compared with those in the lowest category. No effect was seen in prevention of anxiety symptoms after adjustment for other aspects of psychological style. In predicting the onset of heavy substance use and antisocial behavior, high optimism had modest protective effects.
Optimistic thinking style is somewhat protective against adolescent health risks; the clearest effects are seen against depressive symptoms. Promoting optimism along with other aspects of psychological and emotional style has a role in mental health promotion that is likely to be enhanced if an intervention also addresses risk and protective factors in an adolescent's social context.
Purpose:
To explore experiences of care at the Royal Children's Hospital Gender Service (RCHGS).
Methods:
A total of 114 parents and 52 patients of the RCHGS completed an experience of care survey.
...Results:
Most participants highly rated elements of the family-centered care and multidisciplinary team at RCHGS. The majority were satisfied with the RCHGS (parents: 88%, patients: 92%) and would recommend the service (parents: 95%, patients: 89%). Reductions in distress after participation in RCHGS were noted. Wait time was an area of dissatisfaction. Ideas for improvement concerned information giving, family support provision, and improving access to care.
Conclusion:
This study affirms the multidisciplinary family-centered model used at RCHGS.
There is an elevated co-occurrence of autism in trans individuals, with recent meta-analyses suggesting that 11% of trans individuals are autistic. The presence of autism in trans young people can ...create clinical challenges by adding complexity to the presentation, assessment and management of those presenting to gender clinics. Although many trans young people display traits of autism, how these traits relate to the nature of their gender diversity is unclear.
This study compared gender identity, gender expression and gender dysphoria (GD) in trans young people with and without autistic traits. Baseline data from a cohort study of trans children and adolescents who first attended the Royal Children's Hospital Gender Service (Victoria, Australia) between February 2017 and January 2020 were analysed cross-sectionally. Autistic traits were assessed via the Social Responsiveness Scale-2. Gender was assessed using tools that measure gender identity, social transition, GD, body dissatisfaction, voice dysphoria, and chest dysphoria.
522 participants were included, of whom 239 (45.8%) exhibited autistic traits (SRS total T-score ≥60). Those with and without autistic traits were similar in their age (mean (SD) age 14.0 (2.9) and 13.1 (3.6) years respectively) and gender identity: the majority (73.7% (n = 174) and 70.5% (n = 198) respectively) identified in a binary way. Higher rates of social transition (specifically, changing pronouns) were noted in those with autistic traits (Difference in proportion 11.7, 95% confidence interval CI 2.4–21.1, p = 0.014). GD was high in both groups with ∼95% displaying clinically relevant levels of GD. Chest dysphoria was similar between groups, while voice dysphoria was higher in those with autistic traits (standardised mean difference SMD = 0.3, 95% confidence interval CI: 0.1–0.5 p = 0.00087). Dissatisfaction with secondary gendered characteristics (SMD = 0.3, CI: 0.1–0.5 p = 0.0011) and hormonally unresponsive body characteristics (SMD = 0.2, CI: 0.1–0.4 p = 0.016) was higher in trans young people with autistic traits.
The similarly high severity of GD in those with and without autistic traits reinforces the importance of trans young people with and without autistic traits being availed the same opportunities to access gender-affirming care. Subtle differences identified between the groups in other areas of gender diversity suggest trans young people with autistic traits may have distinct needs and that gender-affirming care may need to be tailored accordingly.
The Royal Children's Hospital Foundation, Hugh D.T. Williamson Foundation; Australian National Health and Medical Research Council—Clinical Trials and Cohort Studies scheme (GNT 2006529).
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