Children and Young People: Partners Policy 2023

by | May 31, 2023 | News

Children and Young People: Partners Policy 2023

Dr Helen Webberley and GenderGP have created the Children and Young People: Partners Policy 2023.

Working with Partners

As a result of the recent updates to the World Professional Association of Transgender Health Standards of Care and in line with The Equality Act 2010, from 30 June 2023, we will no longer work directly with providers who withhold services on the grounds of age, when they would provide similar services to young people who are not transgender.

Obviously, we will continue to respect all professional and regulatory compliance duties and are willing to provide any reassurance necessary that our patients are treated in line with internationally recognised standards of best practice and care for transgender people.

This directive applies to therapists, pharmacists, pathologists, surgeons, physicians and any other qualified, registered healthcare professional offering services to adults and young people.

Background

GenderGP’s mission is to enable every gender-incongruent person from all over the world to access safe, effective and compassionate information, education and healthcare, as and when they need it.

We must expect that all people who provide caring services to trans people do not discriminate on the basis of any of the characteristics protected by The Equality Act, and this includes age.

Medical intervention options for individuals under 18 who have reached Tanner stage 2 of puberty, include puberty suppressant agents and gender-affirming hormones. There is ample evidence to show that these are safe, effective and well-tolerated in allowing gender incongruent young people to align their personal goals with their gender identity and to alleviate gender dysphoria.

GenderGP have been providing gender-affirming care since 2015 and have helped thousands of people achieve their goals. Despite political and societal prejudice and fear against transgender identities, GenderGP has stood resolutely in its support of trans people and the vision of a world where discrimination and prejudice do not exist for this cohort.

Many professional providers of care have chosen not to support young people, mostly due to fear for their own professional repercussions rather than taking regard to current medical evidence and best practice. There is a lack of education in this field of medicine and a lot of fear that leads to decisions that are not always in the best interests of the public who are accessing healthcare. People deserve properly regulated, safe and effective healthcare, and by being denied this care they can turn to less safe, unregulated sources of medication that are poorly monitored.

The World Professional Association of Transgender Care published its Standards of Care version 8 in 2022 and they have made recommendations for the care of gender diverse adolescents. GenderGP firmly stands by these recommendations and all care for our patients is provided in line with this guidance.

Clinical Guidelines Adopted by GenderGP

Guidelines

WPATH Standards of Care Version 8 – 2022

What is the expert consensus?

Social Transition

‘We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity.’ Statement 7.12

Age of Consent

‘To be able to make such an informed decision, an adolescent should be able to understand the issues, express a choice, appreciate and give careful thought regarding the wish for medical-affirming treatment.’

‘The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.’ Statement 6.12.c

‘We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.’ Statement 6.11

Binding and Tucking

‘We suggest health care professionals provide transgender and gender diverse adolescents with health education on chest binding and genital tucking, including review of the benefits and risks.’ Statement 6.6

Puberty Blockers

‘The adolescent has reached tanner stage 2 of puberty for pubertal suppression to be initiated.’ Statement 6.12.f

Hormones

WPATH have removed their age recommendation for gender incongruent youth wishing to access hormonal therapy.

‘When considering the timing of initiation of gender-affirming hormones, providers should compare the potential physical and psychological benefits and risks of starting treatment with the potential risks and benefits of delaying treatment.’

Neurodiversity

‘Neurodevelopmental differences, such as autistic features or autism spectrum disorder (see Statement 6.1d, e.g., communication differences; a preference for concrete or rigid thinking; differences in self-awareness, future thinking and planning), may challenge the assessment and decision-making process; neurodivergent youth may require extra support, structure, psychoeducation, and time built into the assessment process (Strang, Powers et al., 2018).’

These traits present us with difficulties in ‘assessment’ but they should not provide unnecessary barriers to necessary care.

Surgery

‘The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.’ Statement 6.12.g

Statements of Recommendations – WPATH SOC 8

  • 6.1- We recommend health care professionals working with gender diverse adolescents:
    • 6.1.a- are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
    • 6.1.b- receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
    • 6.1.c- receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
    • 6.1.d- receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
    • 6.1.e- Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.
  • 6.2- We recommend health care professionals working with gender diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.
  • 6.3- We recommend health care professionals working with gender diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.
  • 6.4- We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent.
  • 6.5- We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
  • 6.6- We suggest health care professionals provide transgender and gender diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.
  • 6.7- We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.
  • 6.8- We recommend health care professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender- related surgery until the transition is made to adult care.
  • 6.9- We recommend health care professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.
  • 6.10- We recommend health care professionals working with transgender and gender diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects including the potential loss of fertility and available options to preserve fertility within the context of the youth’s stage of pubertal development.
  • 6.11- We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):

  • 6.12- We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
    • 6.12.a- the adolescent meets the diagnostic criteria of gender incongruence as per the ICd-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICd, other taxonomies may be used although efforts should be undertaken to utilize the latest ICd as soon as practicable.
    • 6.12.b- the experience of gender diversity/incongruence is marked and sustained over time.
    • 6.12.c- the adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
    • 6.12.d- the adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
    • 6.12.e- the adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
    • 6.12.f- the adolescent has reached tanner stage 2 of puberty for pubertal suppression to be initiated.
    • 6.12.g- the adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

Appendix ONE: Standards of Care for the Health of Transgender and Gender Diverse People – Version 8

For the full Standards of Care, version 8, click HERE.

Adolescents:
6.1- We recommend healthcare professionals working with gender diverse adolescents:
6.1a-Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
6.1b- Receive theoretical and evidence-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
6.1c- Receive training and have expertise in gender identity development, and gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
6.1d- Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
6.1e- Continue engaging in professional development in all areas relevant to gender diverse children, adolescents and families.

6.2- We recommend healthcare professionals working with gender diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.

6.3- We recommend healthcare professionals working with gender diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and this be accomplished in a collaborative and supportive manner.

6.4- We recommend healthcare professionals work with families, schools and other relevant settings to promote acceptance of gender diverse expressions of behaviour and identities of adolescents.

6.5- We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.

6.6- We suggest healthcare professionals provide transgender and gender diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.

6.7- We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.

6.8- We recommend healthcare professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender-related surgery until the transition is made to adult care.

6.9- We recommend healthcare professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.

6.10- We recommend healthcare professionals working with transgender and gender diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects including the potential loss of fertility and available options to preserve fertility within the context of the youth’s stage of pubertal development.

6.11- We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, healthcare professionals working with transgender and gender diverse adolescents involve the parent(s)/guardian(s) in the assessment and treatment process unless their involvement is determined to be harmful to the adolescent or not feasible.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (all must be met):

6.12- We recommend healthcare professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
6.12a- The adolescent meets the diagnostic criteria of gender incongruence as per the ICd-11 in situations where a diagnosis is necessary to assess healthcare. In countries that have not implemented the latest ICd, other taxonomies may be used although efforts should be undertaken to utilise the latest ICd as soon as practicable.
6.12b – The experience of gender diversity/incongruence is marked and sustained over time.
6.12c- The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
6.12d- The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent and gender-affirming medical treatments have been addressed.
6.12e- The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
6.12f- The adolescent has reached tanner stage 2 of puberty for pubertal suppression to be initiated.
6.12g- The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

Appendix TWO: Consequences of Non-Compliance

We take the issue of discrimination very seriously and will not accept any direct or indirect discrimination on the grounds of age, gender or any other protected characteristic. Non-compliance with this policy will result in the termination of the partnership with GenderGP. We reserve the right to terminate partnerships at any time, if we have reasonable grounds to believe that discrimination is taking place.

We understand that it may take some time for our partners to adapt their processes and procedures to fully comply with the policy. Therefore, we are committed to working with our partners to help them meet the requirements set out in this policy.

However, our partners cannot refuse to supply services to our members under the age of 18, based solely on their age. All patients under the age of 18 must be treated with respect, dignity, and without discrimination. We expect all our partners to work towards the same aim of providing safe, non-discriminatory care to all our members, regardless of age.

We are committed to supporting our partners in addressing any concerns related to the safety or validity of the treatment being provided. As part of this commitment, we will provide our partners with the most recent clinical guidelines to help them comply with the policy and ensure safe and effective care for all patients under the age of 18.

We acknowledge that in certain circumstances, our partners may need to return prescriptions of patients under the age of 18. The following are examples of such circumstances, based in the data we have:

  • Incorrect patient information
  • Duplicated prescription
  • Incomplete/missing/incorrect dosage instructions
  • Prescription falls outside of the agreed prescribing protocols.

However, it is important to note that refusal should only occur in exceptional circumstances and our partners should always make every effort to provide safe, non-discriminatory care to all patients including those under the age of 18. We encourage our partners to communicate any difficulties or concerns they may have in complying with the policy and to work with us to find solutions that ensure all patients receive the care they need.