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What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study
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  • Published on:
    Response to authors
    • Roberto D'Angelo, Psychiatrist and Psychoanalysi Institute of Contemporary Psychoanalysis, Los Angeles
    • Other Contributors:
      • Shirley Prager, Psychiatrist
      • George Halasz, Adjunct Senior Lecturer
      • Juan C d'Abrera, Psychiatrist
      • Ron Spielman, Retired Psychiatrist and Psychoanalyst
      • Philip Morris, Psychiatrist

    A recent article in The Times asks: "How will this play out in the next decade, as the first cohort on puberty blockers come to terms with their probable infertility? Such experimental paediatric medicine has been politicised and shrouded in secrecy for too long. It is time to ask serious questions.”1

    In the spirit of asking serious questions of the RCHGS Trans20 study, we stand by our previous claims and respond to the author’s comments, which clearly misrepresented our concerns. Based on our reading of the data, we are of the view that gender-affirming interventions, be they psychosocial or medical, do not have an adequate evidence base to warrant their widespread use as routine medical care in children and adolescents. In fact, the paper’s authors acknowledge this lack of evidence and highlight the “urgent need for more evidence to ensure optimal medical and psychosocial interventions”.

    In their response to our comments, the authors justify their claim that the Trans20 study is an observational study by referring to the NIH definition that an observational study is one in which “participants may receive interventions that are part of their routine medical care”. We do not agree that gender affirmative treatments, particularly medical interventions, constitute “routine medical care”, especially when there are only two small follow-up studies that report short term outcomes of young people who have undergone puberty blockade.2,3 This view is supported...

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    Conflict of Interest:
    None declared.
  • Published on:
    Authors' reply
    • Ken C Pang, Clinician Scientist Fellow and Team Leader Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
    • Other Contributors:
      • Michelle A Tollit, Research Officer
      • Carmen C Pace, Research Officer
      • Michelle M Telfer, Paediatrician and Head

    We appreciate the opportunity to address the concerns raised by D’Angelo and colleagues in relation to our recently published protocol for the Trans20 study [1]. While we certainly welcome feedback on our study, D’Angelo and colleagues focus much of their commentary on the clinical care of young people with gender dysphoria rather than on the Trans20 study protocol itself. In addition, the letter contains a number of inaccuracies and misconceptions that we feel must be clarified.
    Firstly, the authors claim not only that the study “intervenes in the developmental trajectories of all 600 expected participants” and that the model involves “a uniformly stepwise progression through the social and biological stages of transition”, but also that The Royal Children’s Hospital (RCH) Gender Service offers biological interventions to children as young as three. These assertions are incorrect. While patients and families attending the RCH Gender Service routinely receive mental health input to assess, explore and support their gender identity, the use of medical interventions occurs in only a minority of patients, reflecting the highly individualised approach to care. More specifically, a recent 10-year audit of the service from 2007-16 (up until the inception of Trans20) revealed that only 23% of patients received puberty blockers, while an even lower figure of 20% received gender-affirming hormones, and no patient under 10 years of age received either of these medical interven...

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    Conflict of Interest:
    KCP is a member of the Australian Professional Association for Transgender Health (AusPATH) and on its research subcommittee. MAT and CCP are both members of AusPATH. MMT is a member and President of AusPATH.
  • Published on:
    What constitutes informed consent in the treatment of childhood gender dysphoria?: some comments on the Trans20 study
    • Roberto D'Angelo, Psychiatrist Institute of Contemporary Psychoanalysis, Los Angeles
    • Other Contributors:
      • Juan C d'Abrera, Consultant psychiatrist
      • George Halasz, Adjunct senior lecturer, psychiatrist
      • Philip Morris, Psychiatrist
      • Shirley Prager, Psychiatrist
      • Ron Spielman, Psychiatrist and Psychoanalyst

    We wish to express concerns about the Trans20 longitudinal cohort study of transgender and gender diverse (TGD) youth from Melbourne’s Royal Children’s Hospital Gender Service (RCHGS) presented in the BMJ (Tollit et al BMJ Open 2019:9).

    While we agree with the authors that in regard to the management of TGD youth there is ‘’urgent need for more evidence to ensure optimal medical and psychosocial interventionsi”, we have grave reservations about the ethical underpinnings and methodology of the study as described.

    The Trans20 study aims to “document the natural history of gender diversity presenting in children”. It is not clear to us how the methodological design could allow observation of the ‘natural’ history of TGD youth when it intervenes in the developmental trajectories of all 600 expected participants. Given that a vast majority of young people who commence puberty blockers proceed to cross-sex hormonesii, it may well be the case that early intervention ‘locks’ a child into a persistent gender incongruence, closing them off to future choices in identity. We already do possess good data on the ‘natural history’ of gender confusion which shows that a majority of children desist at puberty and return to a gender identity congruent with their natal sexiii. Is this fact presented to concerned families?

    The RCHGS adopts an exclusively gender-affirming model of care, offering psychosocial and biological interventions to children as young as 3. Although...

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    Conflict of Interest:
    None declared.