Transcript for
Working with trans and gender diverse children

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Sophie Guy [00:00:08] You’re with Sophie Guy, and today I’m joined by Associate Professor Michelle Telfer to discuss mental health and wellbeing in trans and gender diverse children. Michelle is a paediatrician and adolescent medicine specialist. She is currently the head of Department of Adolescent Medicine at the Royal Children’s Hospital in Melbourne. She is also the director of the RCH Gender Service. In addition to improving medical and mental health services for the transgender population, Michelle played a major role in successfully advocating for legal reform, with transgender young people now able to access hormone and surgical treatment without the need for approval by the Family Court of Australia. She is also the lead author of The Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents.

Sophie Guy [00:00:53] Thank you very much, Michelle, for joining me today, coming in to have a conversation about trans and gender diverse children.

Michelle Telfer [00:00:59] Thank you for having me.

Sophie Guy [00:01:00] I want to start off first of all, just to ask you a bit about your background and how you came to be working in this space.

Michelle Telfer [00:01:07] So I’m a paediatrician who trained in adolescent medicine, which is an unusual specialty, which really brings together mental health and paediatrics in a medical context together. And much of our work is where the mental health and the physical health overlap. About seven years ago, there was a professor of endocrinology called Garry Warne, who was working at the Royal Children’s Hospital. And he’d looked after the first young people who’d come to the hospital who were trans and gender diverse and who wanted medical intervention in their journey. And when Garry retired, he needed to find someone to take over his work, and I was one of the people that he approached do that. I didn’t really have much experience in working with trans and gender diverse young people. I didn’t have any actually. I had really only known one person before as an adult who had transitioned. But when I started to meet these young people, I really enjoyed it and and really felt that it was a worthwhile area to to assist in. I think to come forward and ask for help when you are trans or gender diverse is difficult within itself. And many of these young people think about themselves deeply and are very thoughtful about who they’re going to tell and how they’re going to tell them. And I feel very privileged when they come in and want to talk about that to me, because I know it is very personal and I know it’s difficult. And the fact that they can do that means that as a person, they have certain qualities and a certain sense of themselves in wanting to have a life where they live their life in their best self. And I really like that about these young people, its ability to come forward and say, this is who I am and I want you to help me to live a good life. And I also like the fact that, generally speaking, they’re really appreciate the work that we’re doing. And that’s very rewarding for me.

Sophie Guy [00:03:19] Yeah, it must be.

Michelle Telfer [00:03:20] Yeah, when I met one of the first patients that I saw, he was a young boy, a young trans boy, and I asked him when he first started thinking about his gender. And he said that the first time he can remember was when he was four and he was blowing out candles on his birthday cake. And when he blew out the candles, he said, my… to himself, his wish was that his body changed into a boy’s body. And he was 10 at the time that I met him and he said every single year, every time he blows out candles on a birthday cake, that has been his wish. And for me, at that time, having not met many of these young people, I thought I can be part of making that wish come into reality for him partly, not totally, of course, but I can help him with with that and something he’s wanted for such a long time and something that was very important to him. And I felt that was an amazing thing, that we were being offered to get involved in.

Sophie Guy [00:04:27] Hmm wow, so this was about seven years ago you started working in the service?

Michelle Telfer [00:04:30] Yeah. 2012.

Sophie Guy [00:04:32] Okay. And I was going to ask you a bit about the gender service at the Royal Children’s Hospital. Did it exist then?

Michelle Telfer [00:04:40] It’s evolved over a number of years. So the first person who ever presented to the gender service was a young trans boy. That happened in 2003. The second young person that came forward was in 2005. And then the third in 2007. So very low numbers initially. When I joined the service in 2012, what we found that year was that we had eighteen new referrals, so few more, but still totally under control in terms of being able to respond to that. But we’ve seen a really rapid rise in the numbers since then. So this year, for example, we’ll probably receive around three-hundred new referrals just this year. Yeah, last year we received two-hundred and sixty-nine referrals. So it’s gone from literally eighteen in 2012 to a number that is quite extraordinary, really.

Sophie Guy [00:05:38] And what do you attribute the increase to?

Michelle Telfer [00:05:40] Well, I feel that it’s due to the increase in society’s acceptance of transgender people and their identity. I also feel that the increased visibility of trans people has allowed others to not feel alone and to connect with others and to realise that there are things that one can do to express themselves in a certain way, which includes not only socially transitioning and changing one’s clothes and hair and an outward appearance, but also undertaking medical intervention. So, for example, with celebrity culture as as one example, there are a number of famous people who have had trans children or high profile people like Andreja Pejic, for example, who has been a model on the front cover of Vogue and many other magazines. And that visibility has not only allow people to identify and help accept themselves, but has really in some ways brought it into the mainstream and made it easier for others to come forward and say it’s okay, this is who I am. And we should be celebrating that, not hiding and feeling ashamed.

Sophie Guy [00:07:01] Perhaps if you could just talk a bit about how does the gender service work and what kind of support and services it provides to kids.

Michelle Telfer [00:07:09] Yeah. So we see anyone from the age of about three is the youngest until they reach the age of seventeen. And our program is very much individualised and patient family centred. So if someone comes in really young, say three or four, there isn’t any intervention that we do apart from talking and exploring how they feel and watching how things might evolve over time. So we don’t do anything actively and we don’t have an agenda in mind, except that our goal is to improve their mental health or to maximise their mental health if their mental health is good when they come in and to support them in however they wish to live their lives. So there is nothing that we do medically before someone goes into puberty. One, because there’s no need. And secondly, it’s a time that children should be able to freely explore who they are and to talk about who they are and what they would like to do. Some young people, when they go into puberty, get extraordinarily distressed about their body changing in, with regards to their what we call endogenous puberty. So the puberty that would naturally come about. If that doesn’t align with their gender identity, that causes extraordinary levels of distress. So you can imagine if you’re a young child and you’re a someone who was assigned female at birth based on your physical characteristics, but you have a male gender identity, if you start to go through puberty and you start to develop breasts, that’s a very distressing situation to be in for these young people. And they often get very distressed about that. It affects their mood in terms of feeling low, feeling depressed, feeling anxious. And we can intervene to prevent that happening by using something called gonadotropin-releasing hormone analogues, which are puberty suppressants or puberty blockers. [Yep]. And what puberty blockers do is at the early stages of puberty, they can stop the physical, secondary sexual characteristics developing. And really provide that young person with time to develop emotionally, to develop cognitively, to explore who they are without the distress of their body changing, so that when they’re a little bit older, when they’re able to consent to treatments that may be irreversible in some way, then they’re able to do that being really well informed without any need to rush into it or to do anything that they’re not ready for. So the puberty blockers are entirely reversible. [Okay]. So you can stay on them for three or four years. And if you decide that you want to live in the gender that you were assigned at birth or they have more of a non-binary gender identity, then you can stop the puberty blockers and natural hormones will just recommence. And your body will change accordingly.

Sophie Guy [00:10:13] It’s yeah, it seems like gender diversity seems an issue where language is particularly important. And so it’s going to ask you, first of all, what is meant by trans and gender diverse, quite broad terms as wondering if you have sort of definitions about it that you work with in the gender service.

Michelle Telfer [00:10:28] Yeah, language is really important, and using affirming language with young people is definitely probably the most important thing to do to help establish rapport and to have them engaged. And for me, the first most important aspect, when we have someone new joining our service, we talk to them about the need to use the young person’s preferred name and their pronouns. And if they’re not sure what their preferred name is, which can be the case when they’re young and they’re changing their preferences for the name and so forth, they might be trying out various names that we asked them. “What name would you like me to use today or what, what are you thinking about in terms of your name and also what pronouns you’d like to use?” Because it’s just courteous, it’s respectful, and it shows that you care about how they feel and that their gender is important to them. So that’s always the first thing. Terms around gender identity (are) changing very rapidly. [Okay]. And well, there are so many terms different people like to use. And there’s certainly no term that fits all. And some of the young people who come to see us who would, we would assume would say that they are transgender male or trans female say, “no, no. I’m male or female. And I want you to use that.” And that’s fair enough. [Yeah]. The terms trans, transgender and gender diverse are very broad umbrella terms that we use in a way that assumes we’re capturing most people. [Yeah]. Or the vast majority, but there are some people who don’t identify with under any of those terms. [Okay]. But it is just a broad term that we use, trans and gender diverse, non-binary is often included in that to complete the umbrella term. But again, it doesn’t include everyone. We need to acknowledge that.

Sophie Guy [00:12:25] Sure. Is there any other language that helps children who are questioning their identity to feel supported?

Michelle Telfer [00:12:31] Yeah, family is probably, well is definitely the most important aspect when it comes to looking at mental health of young people who are trans and gender diverse and non-binary. So if they’ve got a family that are supportive, who use their preferred name pronouns at home, who respect their decisions around what they wear and how they present themselves, and we know that they generally do very well. And we’ve had young people who’ve done astonishingly well, who’ve become school captain or ended up getting top marks in the VCE and going, getting scholarships to university. And so what they can achieve is is incredible and is exactly the same as anyone else when they’re supported. For other young people, we see the detrimental effects of not being supported at home where parents are misgendering them by using the wrong pronouns or even by being abusive, by deliberately calling them names that are derogatory and especially in a gendered way. So we can see how, just how hurtful that can be. And we know those young people have very high rates of depression, anxiety, self-harm, and unfortunately some attempt suicide as well, because for those young people, there really isn’t a safe space for them. You’re not safe at home, it’s unlikely that you’re going to have a safe space at school where your families advocated for you to be safe at school. [Uh-Huh]. And life is just really tough. And I think if you don’t have a safe space to be yourself, then that makes life really, really difficult.

Sophie Guy [00:14:13] Yeah. So it sounds like maybe the mental health that transgender diverse, non-binary children could experience is quite closely linked to the level of support and acceptance they have around them?

Michelle Telfer [00:14:27] Yeah. [Yeah]. So we often talk about the high levels of mental illness in this community and we know that it’s not inherent to being trans or gender diverse or non-binary [yeah], but it’s a result of the negative experiences they have. It’s about the stigma they experience, it’s the discrimination, it’s the social isolation, rejection, particularly family rejection and many trans people experience on a daily basis. Abuse, harassment. [Right]. And it’s that, that contributes. And you can imagine if you have these experiences on a daily basis, even if they’re small, they are accumulative. And for many young people, they’re not small at all. They’re significant and they accumulate, too. And there’s no way someone can have excellent mental health and be highly functioning when they have this persistent, negative life experience. I don’t think it’s possible.

Sophie Guy [00:15:28] Okay. And do you on the whole, do the families that come through, do you find that parents are supportive?

Michelle Telfer [00:15:35] We do have a bias population because you need at least one parent to to support you to come in. I think the most difficult situation and something we come across regularly is when one parent is very supportive and one isn’t. [Okay]. And sometimes those families, most of the time when there’s a significant discrepancy between how the parents feel, it’s in a separated family [okay], where there may be very little contact with one parent or there can even be court orders for around the parenting, and that makes this quite a difficult space to navigate within. We always think about what is in the best interests of this child and try and work around that because that’s why we’re here. And whilst the parents can access their own supports, often the child relies on their parent. So we make the decisions focussing on that young person and try and get the parents to help them as much as they can.

Sophie Guy [00:16:38] Okay. And is that quite a long process for some families and some parents? Yeah. Yeah.

Michelle Telfer [00:16:45] It can be really time consuming. [Yeah]. Can be very rewarding, too. Some of the parents that have been really difficult to engage initially when they have seen the change in their young person, when they have started to accept them in their gender that they are affirming, then you can see really big shifts and you can see relationships change significantly for the better. [Okay]. I’ve had at least one family. I’ve had many, actually, but one in particular that comes to mind where one parent was not wanting this to happen at all and made it very clear that they didn’t want any intervention. But then when the young person was able to navigate that with their parents and and convinced this, this particular parent to come on board, the parent shifted so far that they’ve gone on to advocate for other trans young people and talk about the role of parents in in improving these kids lives. [Wow]. So you can, you can really see how understanding can… just help families come together. [Yeah]. And often it takes a lot of time to help people to leave their, their perceptions behind and their histories behind and to look at things with different eyes.

Sophie Guy [00:18:08] What are some of the main concerns that parents front with? Are there some themes or does it really vary a lot?

Michelle Telfer [00:18:15] I think most parents worry that their child is going to make decisions that they regret in the future. I think that’s the biggest concern that these parents have. And I think it’s an, it’s a natural concern. It’s what all parents worry about their kids and worry that they’re not making the right decisions for them. I think the difference here often is that it’s the young people who are driving this. And for them, it’s not a decision, not a choice. What they’re doing is expressing who they are and what they need to have happen to give them a fulfilling, happy life. So whilst parents might think it’s a decision that they need to be involved in, and that’s certainly the case for the young people, they don’t see it as as a choice. [Uh-Huh]. And parents will often say, “what will happen? Like, what are the risks of regret? What are the rate at which you see it?” And the research around this is is pretty clear that that risk of regret is low. So the biggest study we’ve got comes from Amsterdam. That’s a big cohort study, it was a study that looked at all the people who went through the Amsterdam clinic from 1972, I think, to 2015. So they had more than six thousand trans people who had undergone treatments. [Yeah]. And their rate of regret was somewhere between 0.3 and 0.6 per cent. So it’s very small. [Yeah]. And many of those people didn’t regret the treatment because they changed their gender identity, but more that they had had social situations that they regret having happened to them. So, for example, someone may have suffered from family rejection, from transitioning or may have lost their job. So they regretted transitioning for those reasons. [Okay]. What we often remind parents is that doing nothing in terms of providing intervention is not a neutral decision either, because not providing treatment has its risks. And those risks include poor mental health outcomes, including high risk of depression, anxiety, self-harm and attempted suicide. So whilst intervening has its own risks like everything, not intervening has greater risks and not intervening or parents not supporting the young person to have interventions, what we often see are very fractured relationships within the family. And I think that’s probably the greatest shame of all of these decisions is that families break down because they don’t recognise how important that might be for that young person to fulfil what they need.

Sophie Guy [00:20:59] In the National Workforce Centre for Child Mental Health, Emerging Minds, we have developed about six practice positions that we’ve collectively agreed are useful sort of guides for how to work effectively with children, engage children, engage parents. And we have this idea of we want to be child-focussed and parent-sensitive in our approach to engagement. I’m just wondering if you could talk a little bit about what that looks like in working with transgender diverse children in the gender service.

Michelle Telfer [00:21:31] For us, it’s about listening and it’s about providing safe spaces for children and adolescents to talk. And that really involves, firstly, not just seeing them with their parents, but seeing them on their own and providing that non-judgmental space where they can say whatever they feel and allow themselves to work through whatever they might want to work through. With decision-making, I think it’s really important in child-centred practice to provide information that had felt mentally-appropriate levels so they really understand what’s happening. And then to truly put it in their hands and say, these are the options, this is what we can we can do to help and allow them to work through that.

Sophie Guy [00:22:25] And what does that look like with, say, some of the younger kids say if you’re sitting with a six-year-old, how do you put that in developmentally appropriate terms?

Michelle Telfer [00:22:35] Yeah, well, with six-year-olds, for us, the main support that we can provide is helping them to express themselves through their clothing or their hairstyle or what have you. And most of the time, these six-year-olds just come out, say, “I’m not going to wear a dress” or “I want to wear shorts”. And that’s absolutely non-negotiable for them. And if it’s not going to do them any harm, go, OK. Well, that’s fine. Just wear shorts, cut your hair, if that’s what they really want to do. Doesn’t provide any risk, there’s no downside. But in terms of what we might say to them is around supporting them to express themselves in that way and say, “would you like me to speak to the school, to talk about you coming in wearing pants?” if they’ve got a particular uniform for example that they have to wear and it’s just supporting them to do those sorts of things. But really, with young children that we’re dealing with, the decisions are not big decisions. They’re often just allowing that young person to express themselves in fairly superficial ways [yeah], that mean a lot to them. And for us, I think what our role is there is allowing these children to show that that’s okay, that they do have some control over how they express themselves and that yes, it may be that others might criticise them for what they wear or how they’re expressing themselves, but actually it is okay and that there is not anything wrong with them, this is a world where should we should be able to express ourselves how we feel we we are and helping them understand that. Because sometimes with the, if we’re focussing on the child and listening to how they’re feeling, what we’re trying to do is help them understand the world around them and why people are reacting in a certain way. It’s often these six-year-olds go, “all I did was wear a dress. I don’t understand why such and such got so angry”. And we can talk about it.

Sophie Guy [00:24:28] How do you help a child understand that?

Michelle Telfer [00:24:31] Just usually often by asking lots of questions. [Yeah]. And asking them about, you know, how trying trying to help them think about how someone else might be thinking or how someone else might be feeling. And, “why do you think grandma said that?” [Okay]. And, “why do you think mum got upset when that happened? What do you think?” And just try and try to understand where they’re at and then going from there and reassuring them that it’s not necessarily all about what they’ve done.

Sophie Guy [00:25:05] And helping sounds like helping them to come to arrive at their own understanding.

Michelle Telfer [00:25:08] On their own understanding. Because none of us really know what everyone else is thinking. But for these kids, often just helping them explore those thoughts is what sometimes makes them feel safer. [Okay]. And that it’s okay. It’s okay if someone gets upset sometimes. [Uh-huh]. And just as they might get upset sometimes, and that’s okay, too.

Sophie Guy [00:25:36] Yeah. They’re powerful lessons to be learning.

Michelle Telfer [00:25:38] Yeah. And often we we try very hard to conform and to not upset people. And for these kids they often can’t conform and be happy and they can’t be themselves and not upset people and helping them understand that in their own way is hard sometimes, but I think they they they get there.

Sophie Guy [00:26:00] And how do children get to be seen at service? You mentioned GP referrals. Does, do they have to have a GP referral? [Yeah] To go to the gender service?

Michelle Telfer [00:26:09] How how we see them is that we receive a referral. We have a very broad acceptance of referrals in that if someone wants to come and talk to us about their gender, then they can. There’s no expectation that they have a certain desire to transition or that they have a trans identity. I think for us, if someone is coming and asking for our help to understand how they feel about their gender, that’s enough for us. [Okay]. And we direct the referral within the team to make sure that people are getting what they need. And I think that for very young children, especially for someone who’s three, it’s often not the child who’s distressed or has any issue at all about parents wanting to help understand why that three-year-old is saying certain things or refusing to wear certain things. Or, often it’s a child talking about their gender in a way that parents weren’t expecting them to. And parents don’t know what to do. “What do I say to the rest of the extended family? What do I say to the kindergarten? How do I go about this?” And our response around that is trying to understand the family, where they’re coming from, what their social cultural backgrounds might be, and helping them to understand their child’s experience and assisting them in moving forward in a cohesive way. So we often don’t really do much work with the child necessarily, but more talking with the parents.

Sophie Guy [00:27:41] Do you get many children, families coming through from culturally, linguistically diverse backgrounds?

Michelle Telfer [00:27:49] Probably not as many as we should. [Uh-Huh]. I think they are very much underrepresented in our referral numbers and there are obvious reasons for that. I think that trans identities are accepted at varying levels across the world and in different cultures and we see in terms of the referrals that we receive, they certainly do stretch across all socioeconomic demographics. And we do have young people who come from Muslim families, from Jewish families, from fundamentalist Christian Catholic families. So we certainly see a range of religions, we see a range of cultural backgrounds. We have some patients who some families who are Indigenous or identify as Indigenous. But they are underrepresented.

Sophie Guy [00:28:45] Okay. And if, where do families tend to go to first if they realise that their child is questioning their identity, do they tend to go to a GP? Or who finds out about these things in the community?

Michelle Telfer [00:28:59] Often at schools who are first aware. [Yeah. Uh-Huh]. And the GP is usually the first place people go to after they’ve done a search on the internet. [Yeah]. And we get a lot of calls from people asking how they can connect with us and we refer them obviously to the GP to get a referral. [Yeah]. And GPs are increasingly good at assisting these families and know what to do because the whole situation’s changed so much in the last ten years, from us not having much of a service at all to having seen, well, nearly thirteen hundred children over this short period of time, GPs are just coming to know a bit more about it. [Okay]. And even when I was at medical school, and until recently, there was nothing that was provided at medical school around looking after trans children, adolescents or adults. So most of the GPs out there haven’t had any formal training. And whilst we are hoping to bring it in more and more for the future generations of medical students and trainees in various specialties, there’s still quite a large gap in understanding in the medical community generally. But most people will refer on to a specialist services.

Sophie Guy [00:30:22] Yeah, so for potentially any GPs or even other practitioners listening to this. What is effective, what is helpful in terms of providing support at that point before they might go onto a specialist service?

Michelle Telfer [00:30:36] A lot of people talk about their first experience of coming out to a medical person. [Okay]. And they often tell us about how important it was for them because they might have thought about approaching someone for a very long period of time. Even more than twenty years in some cases. So obviously for them, it is a very important moment in their life and that experience can obviously go very well. As it does with some, or is a lasting memory of of not feeling accepted or feeling valued. I think the most important thing for GPs to do is to listen, to try and understand where that person might be coming from and what their needs are. And really, just as I mentioned before, to use their preferred name and their correct pronouns, which says so much about their level of respect for that person and how they feel. And then just to ask what that person would like from them and what they would like them to do. And if it’s refer on to a specialist or to find other resources for them, if they’re not sure and they don’t know much about this area, to direct them to someone who who does.

Sophie Guy [00:31:53] Okay. And are there any particular resources you could recommend that people are good to go to, to get a bit more information perhaps about how to support trans and gender diverse children?

Michelle Telfer [00:32:04] Yes. So there are a number of websites and the Royal Children’s Hospital, for example, has gender service website where we put a lot of useful links. [Okay]. Including links to peer support services, parent support services, importantly, as well as mental health services that are very much friendly to the transgender diverse and non-binary population. [Uh-huh]. There is also an organisation that I’m a part of and president of. Actually, I need to declare my conflict of interest there. The Australian Professional Association for Transgender Health and that has a list of providers on that website. [Right]. Auspath.org and if GPs are wanting to find someone who works in their state in this area, they can go to the website and find a provider.

Sophie Guy [00:32:53] Okay. That sounds pretty helpful.

[00:32:56] Well, I think we might leave it there. Thank you so much for coming in and giving generously of your time.

Michelle Telfer [00:33:01] Thank you, my pleasure.

Narrator [00:33:03] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health, under the National Support for Child and Youth Mental Health Program.