Text version · Health

Australian standards of care: hormone treatment and mental health care

Transcribed from the supplied image of Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents, Version 1.4, pages 17–18. This is an excerpt, not the complete publication or current medical advice. Later editions may exist.

Paragraphs, list numbering and reference numbers are retained; the original multi-column layout has been simplified. References 66–68 are cited in the excerpt, but their bibliography entries were not included in the supplied image.

View original image

Page 17

The ideal time for commencement of gender affirming hormone treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances. There is no empirical evidence to provide objective recommendations for the appropriate age for introduction of oestrogen or testosterone, with previous guidelines using age informed cut-offs based on clinician consensus and the age at which consent for medical procedures is achieved in that particular jurisdiction.

Adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios,66 as is the case with hormone treatment that is partially irreversible. This is an important consideration, with a thorough assessment of competence being a central part of both mental health and paediatric assessments. In addition to ensuring the adolescent is competent to make an informed decision, the timing of commencement of gender affirming hormone treatment will also depend on the nature of the history and presentation of the person’s gender dysphoria, duration of time on puberty suppression for those undertaking such treatment, co-existing mental health and medical issues and existing family support.

On occasion, a trans or gender diverse adolescent may express a desire to medically transition but not be in a position to provide informed consent. The case of an adolescent with an intellectual disability (ID) is one such example.67 Cognitive ability and developmental level may influence the presentation of gender diversity and it appears that those with ID are less likely to receive treatment for gender dysphoria despite guidelines advocating access to the full range of available help and services irrespective of disability.68 In these cases, treatment decisions require an individualised and developmental approach67 and should be made in close consultation with the family, based on the adolescent’s best interest rather than solely on their capacity.

Whilst later commencement of hormone treatment during adolescence provides time for further emotional maturation and potentially lessens the risk that the adolescent will regret their decision, this should be carefully balanced by the biological, psychological and social costs to the adolescent of delaying treatment. Biological implications of delaying hormones include prolonged administration of puberty suppression, where used, with longer suppression likely to be associated with a greater risk of relative osteopenia. Some trans females may also be distressed by linear growth beyond their expected final height due to delayed growth plate closure with oestrogen and testosterone deficiency. Psychological costs may include the negative contribution treatment delay may have on an adolescent’s sense of autonomy and agency, and may contribute to, or exacerbate, distress, anxiety or depression with subsequent increase in self-harm or suicide risk. Lack of control over personal decision making when faced with barriers to care perceived to be arbitrary and/or unnecessary can be especially difficult for adolescents. Social costs of delayed treatment include peer group and relationship difficulties with pubertal development occurring significantly behind expected norms.

Ideally, the decision regarding timing of hormone commencement should be individualised to provide best care for the adolescent, taking into consideration all the factors mentioned above. The decision should be shared between the clinicians, the adolescent and their family with the values and belief systems of all contributors being respectfully considered.

Page 18

The roles of the mental health professional in the assessment and ongoing care of adolescents with gender dysphoria may include:

  1. Assessment of developmental history, gender identity, cognitive and emotional functioning.
  2. Assessment of family support, dynamics and functioning. Provision of family support over time may be necessary to enable a safe and supportive home environment. Provision of support for carers and advocacy to ensure gender affirming environments for adolescents in Out of home care or within youth justice facilities will be necessary in these circumstances.
  3. Assessment of social, educational or vocational functioning. Advocacy on behalf of the adolescent and their family may be necessary to ensure gender affirming support is provided within their educational environment or place of work.
  4. Diagnostic assessment for gender dysphoria in adolescence. The DSM-5 criteria for Gender Dysphoria in Adolescents and Adults 302.85 (F64.1) and ICD-10 codes (F64) are widely used for diagnostic purposes internationally.
  5. Assessment and treatment of co-existing mental health difficulties such as depression and anxiety with ongoing assessment of risk for self-harm and suicide.
  6. Identification of circumstances that may require more intensive psychotherapy and referral where necessary.
  7. Assessment of the adolescent’s ability to consent to medical intervention in collaboration with the paediatrician, adolescent physician or endocrinologist.
  8. Supportive psychotherapy to assist the adolescent in the exploration of their gender identity, preparing for and undertaking social and/or medical transition and provision of post transition psychological support. This should include an exploration of the potential psychosocial impacts of social transitioning prior to medical transition and managing these expectations and difficulties should they arise over time.
  9. Provision of developmentally appropriate counselling regarding the impact of medical intervention on sexuality, sexual pleasure, fertility potential and the options available for fertility preservation.
  10. Referral for fertility preservation as required.
  11. Counselling of the adolescent and their parents/caregivers on the available options for gender affirming surgical procedures such as chest reconstruction with referral where appropriate.
  12. Provision of clinically relevant education about gender identity, gender dysphoria and information regarding local support groups and organisations available to provide support for the adolescent, siblings, parents and carers.
  13. Provision of documentation to assist the adolescent to change identity documents to reflect the adolescent’s preferred name and gender when requested.
  14. Management of timely transition from paediatric to adult services as appropriate.
← Back to Source room