Child and adolescent gender care in the private sector

I believe in child and adolescent gender care in the private sector. This includes intersex as well as trans children who transition. I have seen it save so many intersex and trans lives over five decades.

Does your trans or intersex child need support?

Are you having problems getting an appointment?

Are you aware you don’t have to wait in the private sector?

It’s been 52 years since we opened the first centre offering help to transitioning people. It was 1971 and I was the third partner in a series of three health clubs. In those days we offered hair, make-up and electrolysis for trans people. It had to be top secret because loose tongues could risk vandalism, harassment and exposing the clients to violence. I could not even tell friends and family what we were doing.

I was still at college and running a peer student counselling group for gay and trans people. It was very controversial, and the chancellor was always trying to shut us down. In the end expelling me was the only way he could close it, but I’d already paid to take my exams and got the third highest mark in the country.

As an intersex and trans child trying to transition in 1966, I was used to witch hunts, and was never swayed by attacks upon me, and there have been many by extreme right-wing moralists during my career. The government health system offered extraordinarily limited care, so I utilised as much private care as I could, which saved my life.

Anyone who knows me will tell you I’ve often worked 14-16-hour days to pay for that care when I was young.

As a clinical sexologist, psychotherapist and mental health professional I’ve seen over 3,500 intersex and trans people in our private clinics, many of them children and adolescents. I did work with the National Health System in the UK, but they often took months to pay their bills.

Should the government care for intersex and trans young people?

In an ideal world, care should be provided by the government, but we don’t live in an ideal world. If you look at health budgets you will sex and gender affirming care is hardly funded. Sure, many clinicians in government facilities do great work, but there are never enough of them (1).

Most government healthcare systems are built on disease control principles. They don’t promote health and happiness. There aren’t sufficient funds and there will never be because of competition in the disease control sector.

What this means is massive waiting lists, and in the government sex and gender care sector that can often be up to several years.

The amount of care that may be available when you access a government clinic may also be extremely limited and insufficient in most cases.

It’s a delusion that the best care is in hospitals and government health centres. Go to any emergency ward and see the pressure doctors and staff are under due to inadequate funding.

I understand that disabled, unemployed, or homeless people might not have access to funds. However, many of my patients find funds from relatives or different agencies.

Many of the suicides in young sex and/or gender diverse people are due to the fact they can’t get into government-run clinics (2). Neither they nor their parents knew that help is available in the private sector, without having to queue on waiting lists.

What is good gender care for children and adolescents?

Getting care fast when you or your offspring need it without having to wait months or years for an appointment.

Seeing a clinician who has the time and facilities to deliver global help with back-up information and the appropriate referrals.

Seeing someone who is highly trained in delivering sex and gender affirming care who is not just the next clinician available. (3)(4).

Choose carers that are highly aware of the 70% risk of suicide risk in young trans and intersex people and how to deal with that situation.

The young person’s transition debate

In these days of information overload on the internet so many people have read one book and claim to be experts.

They are not, they just learnt to read. Just because health professionals have letters after their names doesn’t mean they are experts in sex and gender care. It’s a very specialist area.

Intersex children have been transitioning after they were brought-up the wrong gender throughout history. Trans youth have been changing gender roles for thousands of years.

I began to transition myself at 11 years of age in 1966 and it was a disaster because the adults around me didn’t listen to me. When I was 15, I chose not to listen anymore to those who said it was wrong. It was the perfect decision for me and hundreds of thousands of other trans youths. Transition in younger years is not new.

Start listening to what the young people are telling you, not the person who has read one book. No other person can diagnose the need to transition.

The spectrum of sex and gender diverse identities

Whether a young person identifies as male, female, intersex or gender neutral, to name but few identities, it’s entirely up to them. No one in a democracy, not even parents, has a right to force a young person to identify as they do not wish to.

That would be bullying.

For many young people they are noticeably clear how they identify and that remains constant for life. They know intuitively how they want to live their lives.

Others are on a journey of exploration. They are trying to work out what’s right for them. They may go through stages of identifying one way and then differently.

None of these identities are right or wrong, they are just part of the human spectrum of experience. Everyone who comes into our clinic is fully and positively valued for how they present.

Will they regret transition later?

There are no guarantees in life, except with toasters and similar items.

Transition is an open phrase that means many different things to many different people and that’s okay. There are no exact restrictions or ways you must be.

The research figures, over 30 years, have found that around 95% of transitioning people are happy with the way they live their life. Children who transition generally establish permanent identities (5). From a clinical and research perspective this is a very high level of satisfaction. Few treatments in healthcare could claim that success rate.

According to the research, the 5% who are unhappy with transition co-ordinate with the average figure of 5% of the population who experience mental health problems. Some of those cases become involved with extreme religions that pressured them to de-transition.

The press over the past few years has sensationally highlighted cases of people who are detransitioning. It’s important to remember these are very few people compared to the 95% satisfaction rate. Also, only a minuscule fraction of the 5%, who are not happy actually detransition. So, the detransition rate is less than 1%.

I have seen around 35 people in my clinic to detransition. They originally all transitioned elsewhere in other clinics. The one single common factor between them is that they had very little or good psychotherapy pre-transition.

Screening trans and intersex people

Screening has an extremely abusive history, with non-intersex and non-trans clinicians trying to force people to fit into sex and gender stereotypes. No one should have treatment forced upon them or be denied the treatment they need (6). It was and still is in many ways trying to make us wrong as human beings. It is sexism and genderism and known in sociology as “othering’.

There can never be a test to tell if someone genuinely needs to transition. We are all so different so most of the results would be false negatives or false positives.

My clinical approach has always been respectful discussion and exploration of the person’s journey with the person themselves. This includes young people. It takes time and I ask people to attend clinic regularly.

Only with this can the person seriously consider their situation. Part of my job is to reflect to them how they are presenting so they can gain multiple perspectives.

So, I never stand in the way of people transitioning but I do ask for us to discuss it thoroughly in therapy. We also do not misgender people which is extremely demeaning (7).

Of the 3500 trans and intersex people I’ve seen in clinic only around 500 transitioned. After therapy approximately 3000 decided not to go through the process. I don’t know of anyone who has detransitioned after transitioning in my clinic. The reason I believe this is the case is because we talk it out all the way through transition with no judgement.

When can young people start the transitioning process?

Young children may transition culturally as soon as they can walk and talk, if they have problems with their gender presentation. No medical intervention should be conducted at this age. It’s simply a case of watching and observing them whilst supporting their choices.

Some children will be happy in the gender fluid journey, and for some they may revert to their registered birth sex.

Parents need to support their choices and not make them feel wrong.

At puberty, around tanner stages 1 and 2, some children will want to start puberty blockers to arrest unwanted sexual development as the sex they do not believe they are. Without these blockers, teenagers can become so distressed about the physical changes that they often attempt suicide.

In Australia cross-sex hormones can be administered at 16-year-olds with parental permission (8), or by application to the court without the parent’s permission. In Germany the age is 12 and in some other countries there are no age limits.

Surgery is not advisable before 16 due to the need for the body to grow in other ways.

All of this takes a long time and requires considerable therapy before initiation of these treatments.

In government-funded facilities access to such treatment may be limited; in fact sometimes with a waiting list of several years. In the private sector such treatment is more readily available.

Supporting young people transitioning

For young people, transition can throw up many demanding situations that you might not know how to deal with.

These include how to deal with school, family, friends and particularly bullying.

Therapy is also about teaching you techniques to deal with these situations. Fear arises from not knowing how to deal with them and when you learn how to, life becomes much easier.

Also, you may panic because of the levels of transphobia and intersexphobia in society. It can be frightening.

However, again many of us as therapists have been dealing with this for many decades and can help you negotiate those situations.

One of the most important parts of therapy is to teach you how to have a successful and happy life. To have hope, optimism and create a wonderful life, no matter what your sex or gender.

The risk of suicide

I can’t write about transition in young people without reviewing the risk of suicide. In some studies suicide thoughts in gender-challenged youth are up to 70%, attempted suicide 45%, and often completed suicides (9).

The drive to suicide is for many reasons including bullying, frustration about treatment being denied, and exposure to health professionals who do not understand sex and gender diversity. One of the greatest drivers is having unsupportive parents. When the parent is opposed to their child having help, the risk of suicide escalates dramatically.

What we know is that young people who are positively supported by parents and clinicians have a far lower risk of suicide.

It’s paramount that parents and carers pay attention to this risk and don’t dismiss the young person’s distress. When I am working with suicidal intersex and trans people or youngsters I am very clear that it is a medical emergency that needs to be dealt without delay.

Support for families

There are three kinds of families that affects young intersex and trans people’s situations.

The first is positive, willing to adapt and learn.

The second are mainly those who live in chaos and don’t really do what needs to be done.

The third is the toxic family who are aggressive, opposing the young person’s choices and trying to shut them down.

As therapists we are here to support families and help them learn what to do in these situations. We can teach the family how to cope and give supporting information.

We are also here to answer all your questions. Families often come into clinic having read a story in the newspaper or on the internet that is completely misleading, and they are panicking.

As healthcare professionals we are not here to be punching bags for oppositional families, so it is important to have a polite and respectful attitude during consultations.

What NOT to do if you’re a parent

• Don’t wait for government facilities to see you or your offspring fast. Long waiting lists ruin lives.
• Suicide is a major risk for young intersex and young trans people – don’t wait for treatment because it may end up being too late.
• Don’t take expensive holidays, travel business class, or buy designer clothes; instead be frugal and careful with your health budget.
• Never get caught up in the politics and idealism of health care. Politicians are there to be reelected, not to facilitate your family. Your offspring don’t need you to be woke, they need you to be caring.

What NOT to do as a young person

• Don’t get angry at others; they are not you, and they may be very confused about what you are going through.
• Locking yourself away and hiding is not the answer. Reach out for help when you need it to family, friends, carers, and other people who are like you as part of social networks.
• If you are distressed, don’t think your life will always be like that because it won’t. Look forward optimistically.
• Try not to manage everything on your own. It’s a lot to manage defining your sex and gender when you are young.
• Let people help you.

What to do if you’re a parent

• Be flexible and willing to learn, and support your offspring.
• Remember you are there to care for them, not to make them another version of you.
• Do your research and find help near you or help through the internet if there is none in your area.
• The priorities of health and happiness are the most important things that you can help your offspring achieve.

What to do if you are a young person

• Always remember there are many good and nice people in the world.
• If you feel suicidal about your sex and gender situation, reach out to a suicide helpline immediately.
• If your parents won’t listen, talk to your teacher, lecturer, school, or college counsellor.
• Ask for help now and don’t delay. Be very positive about your future whilst getting the help you need today.

References:

(1) Costin, L. (2023). Sydney gender clinic not working for people: minister. The West Australian. https://www.perthnow.com.au/news/health/sydney-gender-clinic-not-working-for-people-minister-c-11241295

(2) 14-year-old Noah was denied access to gender-affirming treatment. He died soon after. Mamamia. https://www.mamamia.com.au/noah-obrien-trans-boy/

(3) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf

(4) Carpenter, M. (2020)/ Clinical guidelines. Intersex Human Rights Australia. https://ihra.org.au/guidelines/

(5) Olson, K., Durwood, L., Horton, R., Gallagher, N., & Devor, Aaron. (2022). Gender Identity 5 Years After Social Transition. American Academy of Pediatrics, 150(2). https://doi.org/10.1542/peds.2021-056082

(6) US: Harmful Surgery on Intersex Children. Medically Unnecessary Operations Risk Lifelong Suffering (2017). Human Rights Watch. https://www.hrw.org/news/2017/07/25/us-harmful-surgery-intersex-children

(7) Misgendering and experiences of stigma in health care settings for transgender people. Misgendering negatively affects the mental and physical health of trans individuals. (2020). Med J Aust, 212(4). https://www.mja.com.au/system/files/issues/212_04/mja250497.pdf

(8) Ouliaris, C. (2021). Consent for treatment of gender dysphoria in minors: evolving clinical and legal frameworks. Med J Aust, 216(5). https://www.mja.com.au/journal/2022/216/5/consent-treatment-gender-dysphoria-minors-evolving-clinical-and-legal-frameworks

(9) Cook, A., Winter, S., Strauss, P., Lin, A., Wright Toussaint, D., Watson, V. (2017). Trans pathways : the mental health experiences and care pathways of trans young people : summary of results. Telethon Kids Institute. https://anrows.intersearch.com.au/anrowsjspui/handle/1/20351

Dr Tracie O’Keefe DCH, BHSc, ND is a sexologist and world-renowned specialist in sex, gender and sexuality diversity, published researcher of over 50 years’ experience. She is the co-author of Trans-X-U-All: The Naked Difference (1997), author of Sex, Gender and Sexuality: 21st Century Transformations (1999), co-editor of Finding The Real Me: True Tales of Sex and Gender Diversity (2009), co-editor of Trans People In Love (2010), author of Suicide in Intersex, Trans and Other Sex and/or Gender Diverse Groups: A Health Professional’s Guide (2021).

You can consult her in the clinic or by Zoom from anywhere in the world.

Call our central booking for your FREE telephone consultation with Dr Tracie O’Keefe DCH. Phone 0403 398 808