The way we're raising transgender children has to change, according to new guidelines from researchers at the Royal Children's Hospital (RCH) Melbourne and the Murdoch Children's Research Institute (MCRI).
The report is a comprehensive summary for Australian practitioners who work with transgender and gender diverse young people. It rejects both the need for a standardised legal age of consent and the long-term puberty suppression that adolescents are often subjected to.
One of the authors of the guidelines, paediatrician and head of the Department of Adolescent Medicine at RCH Dr Michelle Telfer, told Buzzfeed News that gender-affirming care during childhood and adolescence is the only way to improve mental health outcomes, and decrease rates of depression, anxiety, self-harm and suicide, in this vulnerable population
"We've seen 1,000 young people come through the Royal Children's Hospital over the past 14 years; we see absolutely before our eyes the improvement when these young people are empowered to be who they are," Dr Telfer said.
The guidelines reject aspects of the World Professional Association for Transgender Health (WPATH) Standards of Care, which are conventionally upheld as a global authority on treatment of trans and gender diverse young people.
The new guidelines reject a standardised age of informed consent for hormonal treatment, as the authors assert that adolescents vary in the age at which they become competent to make those decisions.
However the WPATH Standards of Care Version 7, published in 2011, states that stage 2 hormone therapy (oestrogen or testosterone to feminise or masculinise the body) should only be provided to those who are able to legally consent to the treatment, and this sets the minimum age of consent at 16 years old.
Late last year a landmark decision was made in the Family Court that gave transgender youths access to hormonal treatment without court authorisation.
However, the age of medical consent defined by WPATH is still too old, as far as Dr Telfer is concerned. She says "Sixteen was a convenient age, but a totally arbitrary age in terms of other aspects of medical care", and that there is no "actual medical or physical argument for choosing that particular number".
The authors of the guidelines instead believe that case-by-case assessment and individualised treatment that does not abide by chronological age is the most responsible practice. Dr Telfer says that a young person's capacity to understand medical decisions is best assessed by getting to know them and speaking to their family.
Fifteen-year-old Isabelle, a transgender girl and one of Dr Telfer's patients at RCH, began stage 2 earlier this year and is relieved that she did not have to wait another year: "I think I started at a good time for me personally — since I was 11 I've been wanting it, so any time feels a bit late, but I think when I took it was the healthiest time."
By defining 16 as the acceptable age of consent for stage 2 treatment, the WPATH guidelines put trans youth at risk of the side effects of puberty blockers by extending their stage 1 treatment, says Dr Telfer. "If that young person happened to start puberty at age 10, five years of puberty blockers has problematic effects on bone density and bone health."
Mental health is also affected when a trans adolescent is forced to start puberty at 16, the age they are permitted to begin stage 2 treatment.
"If you're suppressing puberty at a young age and then waiting five years while your peers go through puberty, there are consequences," Dr Telfer said.
Isabelle says she would have been upset if she had to endure such a delay: "I just wouldn't be very comfortable because that would mean I'd have to stay in this sort of pubescent limbo for even longer and that just isn't a fun place to be."
Seventeen-year-old Freya is a transgender girl and a patient at RHC. She says the current rules are unfair to trans teens.
"It shouldn't be on an age, it should be on a maturity basis," she said. "Especially for queer teens, they may not have the best relationship with their parents, they're often striving for more independence by 16."
Dr Telfer maintains the importance of the shift in the new guidelines. "It's very clear to us and to other clinicians who work in the area that this is not about ideology, this is about scientific evidence and an evidence-based program that helps these kids."
The trans community is already deeply vulnerable to mental health issues. Nearly half (48.1%) of trans young people had tried to kill themselves (20 times higher than the general population in the same age bracket of 12-17), and 74.6% were diagnosed with depression (10 times higher than adolescents in the general population).
Isabelle is excited about the new guidelines and believes they can help young people suffering from dysphoria.
"Now they can move at a pace that's healthy for them, they can go at the pace they should be going and they can go with everyone else."
If you need to talk to someone, you can call Lifeline Australia on 13 11 14 or Beyond Blue Australia on 1300 22 4636. Anxiety UK on 08444 775 774, or Hopeline America on 1-800-784-2433.