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Major concerns over Australian study into transgender children

Some very well-respected psychiatrists have raised serious concerns about the ethics and methodology of a new prospective study into transgender children, taking place at Melbourne’s Royal Children’s Hospital Gender Service.

The protocol of the study, known as the Trans20 longitudinal cohort study, has been recently published in the journal BMJ Open.

In essence, the study aims to track the long-term outcomes of children and adolescents who have presented to this service over the last three years (from February 2017 to February 2020). Researchers estimate that the final number of participants will be about 600.

There is no disputing the fact that the issue of people identifying with a gender different to the one with which they were born has become increasingly common (or at least increasingly recognised) over the last decade. And this issue is causing significant mental distress The study authors say their service at the Royal Children’s Hospital is seeing approximately 250 new referrals a year, including children as young as three.

Another fact that everyone agrees on is the fact that we have very little robust scientific evidence on how best to treat children who present with this ‘gender dysphoria’.

The study authors certainly acknowledge this.

“Looking ahead, it will be paramount to fill existing knowledge gaps and determine empirically how best to manage the care of [trans and gender diverse] young people so that future best practice guidelines can be based on as much robust evidence as possible.”

But after this is where things get a little controversial.

“[The Trans20 study] will provide integral information on the natural history of gender diversity,” the researchers said.

And this statement highlights the major criticism of the study, raised by a group of six senior Australian psychiatrists in a letter to the BMJ Open.

How can you work out what the natural history is when everyone has received treatment? It is part of the Melbourne Service’s protocol that every patient receives gender-affirming care.

“It is not clear to us how the methodological  design could allow observation of the ‘natural’ development of [trans and gender diverse] youth when it intervenes in the developmental trajectories of all 600 expected participants,” the psychiatrists said in their letter.

As one of the psychiatrists, Dr Robert D’Angelo said in an interview with The Weekend Australian, “There’s a kind of assumption that the gender affirming treatment being provided is the gold-standard appropriate treatment.”

Also of concern is the fact that the care provided by the service allows a step-wise progression of not only psychological support but also medical interventions, including the use of GnRH analogues “to help prevent the development of undesired physical changes during puberty.”

The critics of this study suggest this medical intervention represents a commitment by a patient who is too young to make it. It effectively locks a child into ‘persistent gender incongruence’.

Given that such interventions require parental consent, “are parents fully informed about the biological and psychological risks associated with delaying puberty through hormone blockers?”, the psychiatrists asked. They also point out that we don’t know whether such drastic treatment actually improves their ‘gender dysphoria’.

The other major issue the critics raise is the fact that the evidence suggest that the majority of children who experience gender concerns eventually go on to identify with the sex they were born with.

Even the study authors acknowledge this.

“Published literature reports that 45%-88% of children with gender concerns in childhood go on to identify with their birth assigned sex in adolescence and adulthood indicating only some of these children report a transgender identity when older,” they wrote in the introduction to their protocol.

So will the Trans20 study have sufficient capacity and flexibility to support this very prevalent gender fluidity, or does it risk closing these children off to future choices in identity, the psychiatrists ask.

It is believed that the Trans20 study researchers are preparing a reply addressing the concerns raised in the letter. Certainly a reply that will be read with interest.

References:

D’Angelo R, Carlos d’Abrera J, Halasz G, Morris P, Prager S, Spielman R. What constitutes informed consent in the treatment of childhood gender dysphoria?: some comments on the Trans20 study. BMJ Open. 2019 Dec 14; 9(11): e032151. Available from: https://bmjopen.bmj.com/content/9/11/e032151.responses#what-constitutes-informed-consent-in-the-treatment-of-childhood-gender-dysphoria-some-comments-on-the-trans20-study

Tollit MA, Pace CC, Telfer M, Hoq M, Bryson J, Fulkoski N, et al. What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study. BMJ Open. 2019 Nov 4; 9(11): e032151. DOI: 10.1136/bmjopen-2019-032151.