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Dr Michelle Telfer, Associate Professor and Paediatrician at The Royal Children’s Hospital, Melbourne, joins Dr Helen and Marianne to talk about Australia’s approach to the treatment of trans youth.

Together they discuss the vital importance of affirmative treatment in achieving positive outcomes for this group of individuals, as well as the groundbreaking work that went into the production of the world’s first set of clinical guidelines for the treatment of transgender adolescence: The Australian Standards of Care in 2018.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please get in touch via the Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

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Links:

Twitter: @michelle_telfer

Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents

The Lancet – Michelle Telfer Article

 

The GenderGP Podcast

Redefining the treatment of Trans Youth – Michelle Telfer: The GenderGP Podcast S5 E7

 

Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr Helen Webberley:
So good morning, everybody, well, it’s early morning for us, and it’s a bit late afternoon for our guest today. So, I’m really excited. I’m with Marianne today. I’m always really excited, but today we have Michelle Telfer with us. Michelle is a paediatrician and doctor in Australia, and she does a lot of work with trans children. And as always, I’ll hand over to you Michelle, to introduce yourself and tell us who you are, what you do, how you ended up doing this line of work everything about you, so over to you to introduce yourself.

Dr Michelle Telfer:
Thanks, Helen. I don’t think you want to know everything about me, but I am Michelle Telfer. I’m a paediatrician and adolescent physician, and I work at the Royal Children’s Hospital in Melbourne, in Australia. And I’m the director of the department of adolescent medicine. And within that department, I’m also the director of the RCH gender service, which is a service that’s grown over the last 17 years to now be a team of approximately 16 people that look after trans, gender diverse, and nonbinary young people from about the age of three up until—we accept referrals up to the age of 17, but we do provide care until we can transition young people into adult help service services around early adulthood. Gosh, talking about everything that everything about me—I was actually born in Perth, which is across the other side of the country in Western Australia, it’s actually the most isolated, one of the most isolated cities in the world, and moved to Melbourne after I finished university in 2001. Actually, moved in 2002, but around a long time ago anyway, and have been at the Royal Children’s Hospital here since 2003. So, I am a, what they call a Melburnian, but also claim to be West Australian as well. I have shoes in both camps, so to speak.

Dr Helen Webberley:
Thank you. Brilliant. So, and so, so you, you said 17 years ago and that’s when you joined, so what’s the, was this service up and running then? Or was it, is there something that you’ve, you’ve been instrumental in developing as, as you know, more and more, obviously more and more people that come forward as being trans or so over the last few years. So, is this, is it a service that you’ve developed or was it already in place kind of thing?

Dr Michelle Telfer:
Yeah, well, I actually didn’t join the service until 2012. So, when I came to the Royal Children’s Hospital in 2003, I was a very junior pediatric resident, really just starting my specialty training. And it was around that time that The Royal Children’s Hospital had its first-ever young person who presented to the hospital needing care. And this young person was about 12 when they presented, and came with a complicated story that involves identifying as trans and really needing to transition to support their mental health. And one of the endocrinologists at that time, professor Gary Warne saw this young person in collaboration with a child and adolescent psychiatrist, professor Campbell Paul, and the two of them provided care for this young person who did go on to transition medically and do very well actually just despite his challenges. It was two years after that that the Royal Children’s were seeing their second young person, their second referral for someone wanting care and then two years after that, but they received the third referral. So, when I came in as an adolescent medicine specialist in 2012, so having done my pediatric and specialty training between 2003, and that time I took over as the clinical lead in adolescent medicine. And it was that time that Gary Warren, the pediatric endocrinologist actually retired. And with his retirement, there wasn’t someone to take over from his role providing support for medical transition. And that’s when I put my hand up to help out. And what’s been really interesting is in 2012, that year we had 18 new referrals. So, it was still relatively small. And there wasn’t a structure around service. I don’t know that you’d even call it a service. It was more a couple of clinicians who were providing care for these young people who were presenting, wanting assistance. But between 2012, when I joined the team where there was the only sort of three or four of us, to 2019, we’ve had such enormous increases in demand that last year we had 336 new referrals. So, it’s gone from a very small kind of group of interested clinicians into now a multidisciplinary service that has very much structured part of laws supported by many clinicians who bring their own expertise. But with the structure that’s required to provide good care to such a large, large number of young people. So at that time we would have had 1500 young people come through the service.

Dr Helen Webberley:
That’s amazing, isn’t it? I mean, I think across the world, we’ve seen that, that increase. And I love the way that you, that you explained your, the first patient. And you said, you know, needing to transition to support their mental health. And it’s a really interesting way of thinking about it, isn’t it? Because you know that there will be people who say, well, they don’t need to transition. What’s, what’s wrong with just staying in their birth-assigned gender, but actually, it is about their mental health, isn’t it? And you know, this is a need. This is something that needs to happen in order for them to, to live a comfortable and happy life very often. So, I love the way that you said that. So, I mean, we were really delighted when you produced the Australian Standards of Care in 2018, you know. The world is crying out for documents and guidelines like that. And I have to say, it’s, it’s a fantastic document. Thank you for doing that. So, from 2012 to 2018, when you wrote that you kind of, how, what were you basing your medicine on? Because that’s often been criticism at us, isn’t it? You know, how do you know it’s the right thing to do? How do you know it’s safe? How did you, how did you as a department and a team approach that?

Dr Michelle Telfer:
Yeah, it’s a good question. When I joined the team, I didn’t know very much at all. I was really quite naive with regards to this area of medicine, it’s not something that we learned about in medical school. I had very little exposure during my training in paediatrics, even in adolescent medicine. So, when I was approached by the hospital to take over Gary’s position, I had to do a lot of reading. And I went to a number of events and conferences to hear the experts speak. But certainly, looking at the evidence, the evidence is very much overwhelmingly in favour of affirmative care and the evidence also really well documents, the damage that is done with either denial of that care, or even in a worst-case scenario, an active denial or conversion type responding to in terms of, not providing that care. And I was really struck by the young people I was seeing and just anecdotally how strong the affirmative stance was in terms of producing really good outcomes. Like at an individual level, you could see the power of allowing a young person to express who they are and supporting them in being who they know themselves to be. You could see in front of your eyes the way that the young person would thrive and bloom and taking the evidence in the larger trials and, and putting it into practice at an individual level for me, was really eye-opening. And there aren’t that many areas of medicine that you can see that difference so profoundly, especially in terms of the work that we do just in talking to young people, but this was an area that I could really feel how rewarding it was to just support young people to be themselves. So, I’ve gone totally off the question, but the reason for bringing this up was that what I was reading in terms of the journals and what I was hearing from the experts, we were putting in practice with these young people that we were seeing, and it was extraordinary to say the great outcomes that, that could come with this. And when I compared that an individual level with the families who weren’t supportive of the young person, just the pain that was experienced by this young person, not being able to thrive, not being able to make their potential in any aspect of their life, whether that was socially, emotionally, educationally, or just in general family function, that it was so clear that supporting this young person, they do really well. Not supporting or actively showing unsupportive behaviour towards a young person was catastrophic for their outcomes. So, I guess what we did as a team was initially to follow the WPath guidelines and to use those guidelines plus the evidence we had in moving forward from those guidelines because as you know, the WPath guidelines were published in 2011 and whilst they were the most progressive guidelines in 2011, between 2011 and 2018, there was a lot of change. And a lot of evidence that was coming out that was suggesting that chronological age used to decide when someone should start hormone treatment, for example, was not necessarily in the young person’s best interest. And we saw the benefits through the data. So, through teams like that in, in (unclear 12:25) and in the Netherlands and others that for some young people needing to transition medically a bit earlier was really helpful for them, whether it was reducing side effects for blockers or improving their psychosocial outcomes from being able to transition, to be able to go through puberty with their peers. Whatever those risks and benefits were weighed upon an individual level, we could improve their outcomes. And I’m not sure if you want me to go into the detail of why we started writing the guidelines, but it has its origins actually in the evidence and how we were moving forward. We had a really unique situation in Australia where we had a law that essentially—this law that was created through case law in 2004 was a case known as Alex. And this case involved a young person who wasn’t living with their parents, and who was actually living in the care of the state. And this young person needed to transition medically but was too young to consent themselves. They were only 12 at the time when they would really be needing to go into blockers, so they couldn’t consent themselves. Legally, they weren’t able to consent. They didn’t have any parents to provide consent, and the state or the government really wasn’t sure about providing consent on their own. So, what normally happens in Australia in this situation is it goes to the family court, which is a federal court, and the court will make an order based on the best interest of the child. And that’s what happened, in this case, is that Alex went to court and evidence was put forward by his treating clinicians and some overseas experts. And the judge, in this case, made an order that Alex could progress with using puberty suppression, followed by testosterone treatment. But unfortunately, the judge in his orders concluded that the situation warranted in the future others coming to court for this same treatment.

Dr Helen Webberley:
Yeah.

Dr Michelle Telfer:
And what that did was to set up a precedent where everyone under the age of 18 in Australia, needed to approach the court for hormone treatment. I do genuinely think that the judge thought that this would be in the best interest of young people. But clearly, as society became much more accepting of trans young people and recognize the need for them to transition during adolescence—also with the numbers coming forward because of acceptance and because of trans visibility and all the great things that we’ve seen over the recent years because more and more young people were coming forward. And the court, we’re seeing more and more cases. And this court process in itself was really damaging. There was a study. There was a study done by a professor of law, Fiona Kelly, who’s also based in Melbourne. And she did a study looking at families, who’d have to traverse the family court to get hormone treatment for their children. And what she showed in that piece of research was that it caused a huge amount of distress for the young people and the families. They often found that their mental health suffered most leading up to the court date. Because obviously, having your own information put out in public for, even if it’s de-identified, it’s still your information that’s being put out into the public arena. You’re put before a judge who you’ve never met before, making a decision around your life, that is probably, I suspect, the most important thing to you at that point in time. And so, locating who you are, yeah, just who you are. And then you’ve got a judge making this decision. Plus it was causing a delay to the treatment of about eight months. And for some families, you weren’t able to get pro bono representation. It was costing up to 30,000 Australian dollars.

Dr Helen Webberley:
Wow.

Dr Michelle Telfer:
So, it was a huge impediment to accessing care. And we really needed to do something about it because it was causing so much harm. And between the time of 2004 and 2017, the court had heard approximately 67 cases. Many more young people had wanted care during that time but had opted to wait until they turned 18 to avoid the court system. And I suspect a large number of young people outside of capital cities, especially in other places where accessing court was not possible, they were potentially even accessing medication through other means. But over this time of the 60 plus cases that were heard, there wasn’t one case where the judge didn’t produce an order to provide hormone treatment for the young person in front of them. And of course, over time too, when you have so many young people coming forward with a similar history of how they feel and what they need and similar experiences in terms of the desire to transition and the need to transition. There was a bit of unease within the judicial system that this was not right and that this was not in the best interest of young people. And it’s discriminatory because there are other situations like this where totally competent young people who are requesting an evidence-based treatment that is in their best interests would ever need to go to court, especially if the young person, the parents, and the clinicians looking after them all agreed it was in their best interest. So, there was a campaign to try and remove this process from the court system and have the clinicians be making the decisions in conjunction, of course, with the young person and their family. And this is a very long story to get to my point, but during the advocacy, what became clear was that there were a number of judges and lawyers and politicians who said if the court isn’t providing good governance over these medical decisions, then how are we going to maintain good governance? How are we going to maintain consistency and ensure that these young people are receiving the best care? And normally in medical circles, as you know, we would follow clinical guidelines, but what had happened between 2011 and 2017 was that the judges were also recognizing that for some young people, sixteen was too late to start hormone treatment. They might’ve been started on puberty blockers from age ten, and wait six years had consequences in terms of their bone density and in terms of the delay for pubertal experience with their peers. And we’d gone to court an earlier age to seek approval, and the judges have given approval for young people to start hormone treatment. Quite a few, a number of young people had started treatment at 15 outside of the WPath guidelines. And one of the difficulties in trying to reach a point of change as we realized that we needed to have new guidelines. And we needed to actually reflect clinical practice in our guidelines and in a searcher around the world. There weren’t guidelines that we could say that we were following that were evidence-based and reflected best practice. So being Australian, you know, we have that kind of larrikin element where we just go, right, well, we just have to make our own, we’ll just do our own. So, we put, we put the guidelines together, it took many, many months. And it was a collaboration across the country and, and included some clinicians from New Zealand. The guidelines also involved a number of children, adolescents, their parents, their siblings, and went through various stages and a number of drafts involving everybody. And then eventually, we had the Standards of Care that we were happy with, we thought we had a consensus for, and, and that reflected the work that we did in Australia. And these were put forward really for the reason of court reform. But also, because it was felt that we really did need to have a guideline that provided that governance in what we do. So, it served a number of purposes. And there was a case that was hurting Australia. It was hurting Sydney, called Re Kelvin. And I was the medical expert called for that case to provide evidence. And I was certainly able to put forward the Australian Standards of Care into evidence as what is best practice internationally? What is conducted internationally by the services that we feel follow the evidence, informed care, and a consequence of putting it out into the public for and, and later having it published in the Medical Journal of Australia exposed it to others internationally, and their response was amazing. I genuinely hadn’t thought of the potential impact at an international level. That was never the intention. But we really did have an incredible response which wasn’t harmed at all by the fact that the Lancet—and I’d just have to, I might just say that word again, the Lancet picked it up and did an editorial on it. And I nearly fell off my chair when they first contacted me because I was genuinely really shocked. But there was obviously a need there, that people wanted to be able to provide good, individualized care that really did look at what was the best treatment options for the young person in front of them. And I think our guidelines allowed that flexibility whilst also keeping containment in terms of the care that’s within the evidence base.

Dr Helen Webberley:
Yeah. I think for me, as a, as a doctor, what it’s given us is permission, you know? It’s written, I think in a very friendly way. And I think it gives permission to those people and clinicians who have that gut feeling that this is the right thing to do, but nothing to back it up with and that’s what was missing, wasn’t it? So, it actually gives permission. And I think probably internationally people were doing this in their day to day practice because they understood it was the right thing to do. But perhaps just being a bit quiet about it because there wasn’t that backup. And so now to have that backup is amazing. And, you know, the first thing that I do and when anything like this comes out as I scan it. And so, I say, please don’t use the word 16, please don’t use the word 16 because that 16 word is such a misnomer. It just shouldn’t be in there. And you know, why should, why does anyone have to wait until 16 to have their life progress? You know, and we’ve, you know, I think around this room, all of us have had teenagers. Teenagehood starts earlier than 16. That 16 is just such a wrong number. I’m going to bring Marianne in here. Marianne, you were a child who didn’t have access to this kind of evidence-based, compassionate experience care. What do you think it would have done for you if this kind of attitude had been around when you were young?

Marianne Oakes:
Oh, wow. Yeah. Firstly, I just want it to say fascinating to see how it’s developed and actually lovely to hear what the response is. I don’t get involved in all of that outside. I just see the people in front of me. Well, yeah, just to see how social change has happened since my childhood. There wasn’t even a conversation, and now there is genuine care out there. It would just have been mind-blowing how, how many lives would have been different, how many lives would have been more fulfilled. And the one thing as Helen knows, and anybody at GenderGP knows my passion is for the youth. Not because I don’t care about the adults, but actually I see what the result is when they didn’t get care as children. I was really fortunate for keeping my own mental health and live together and functioning. So, if we don’t look after the youth, now we’re just going to have another generation of adults that have got missed opportunities, lives not fulfilled, potential not fulfilled. So, hearing what’s happened in Australia in recent times, and just before I finished, the sad part is I haven’t a clue how this is developed in the UK because of the Tavistock have kept hold of everything if I’m allowed to name the Tavistock. But the truth of the matter is, you know, the care in the UK feels like it’s from an NHS level, is held back 20 years and everything I heard you saying that is very 2018, 2020 which is refreshing to hear. Hopefully, others will be hearing your story.

Dr Helen Webberley:
Michelle, I don’t know if you know much about my situation, but I was going to say, I stumbled into this. I mean, maybe I did. In 2015, I was a GP and a sexual health doctor. And I started seeing—that was around the time when people were beginning to come forward, more, not youth but adults. And so, in my everyday practice, people were coming to me saying, you know, can you help me? You’re like the kind of doctor that I can talk to. Can you help me? And that there was just nothing, you know, like a bit like, you know, I didn’t have any experience really in that area. And then when I started seeing what was happening, I was like, goodness gracious. You know this is an area of health care that if we spoke about this, people wouldn’t believe the patient experience that’s going on. And I was really shocked, really shocked. And so GenderGP was founded as a kind of—it started off as an advice place. You know, if you’re trans, this is what you’re entitled to, this is the healthcare that you deserve. You should be able to ask for this kind of thing. And it wasn’t a before long it became as a doctor, you know, you have people coming to you saying, well, you’re a doctor, can you, can you help me? You know, you seem to understand, can you help me? And then it, wasn’t long before the young people started coming and they’re like, well, if you’re helping these adults, could you help me? And I’m like, well, I don’t see why not, because I’m just sitting here. Like you, you know, how you described it earlier, earlier you were just, I was just seeing what benefit, giving gender-affirming care was. It was helping people, astoundingly helping people. It’s transforming their lives. And as a doctor, and exactly, as you said, you know, you coined my words that I often say, you don’t get that chance in medicine very often to make that much of a difference. And I was loving it, I was absolutely loving it, you know, helping people learning, reading everything I could possibly read, helping people, and transforming lives. It’s just, I was just in my element. And then like the sword came down where my colleagues in the UK were like, well, that’s not the way we do it. We don’t do it like that. And we haven’t ever done it like that. And we don’t like you coming in to do it like this. And so actually we’re going to refer you to your regulator, which is our General Medical Council. So, I had a flurry of, they didn’t like pick the phone up to me. They just wrote letters to the GMC. And so, this doctor’s, you know, negligent, this doctor’s behaving, not the way that we behave and you need to do something about it. So, in two thousand—and where are we now? It’s coming up four years. So, in 2017, in May of 2017, I was stopped from working. And then I haven’t been able to work since because of providing care that I could see was happening across the world internationally. I could see other doctors doing exactly what I was doing, but because we don’t do this in the UK, I was stopped. And you’re supposed to be stopped for six months while they just check it out four years later, they’re still kind of checking it out. And it’s really heartbreaking to have your career taken away from you for doing something that you feel so passionate about. And you know, I think many people have said to me, along the way, well, why don’t you just give up, you know, go back. It’s still unable to practice, but you know, why don’t you just stop, give up? Is it worth it, all the tears, the heartache and everything? But I think you only got to see a few of those young faces that you’ve been able to help, transform, and enable. And you know, it’s not something that I can give up. I mean, and I think, you know, I’m not the only doctor across the world who’s taken these brave steps forward and received criticism. But I think for me, the fact that it was criticism from my colleagues that cause has caused this difficulty for me is really, really difficult. And I think Marianne, you know, you said that it seems that the NHS and the UK are 20 years behind and it really does feel like that. And I’m envious, Michelle, of your beautiful guidelines and, and envious that you have a working place where actually it’s absolutely fine to give care to youth under the age of 16, because this is what enables them to, as you said, socially, emotionally, and educationally move on, and have an adolescence with their peers. So, it’s challenging. We see it across the world. We see it on social media. We see it in newspapers. We see it everywhere, the challenges that I think brave women like you, myself, and of course, Johanna in America have faced. But, you know, I think we have to continue bravely forward, don’t we?

Dr Michelle Telfer:
I’m so sorry to hear. That makes a devastating story, an absolutely devastating story. And I, yeah, I can’t imagine having my career taken away from me in a way that’s so profoundly unfair and misguided because—yeah, I’m a bit speechless, actually, because when you are going about your work really to help young people and when you know, you’re helping young people, to have that to be removed is awful. That’s really awful. I don’t really know what to say.

Dr Helen Webberley:
I suppose you know, thank you. But I think the point I was making is this is a challenge. But in order to affect change in our lifetime as clinicians you know, we have to have sometimes some battles on behalf of our patients, don’t we?

Dr Michelle Telfer:
Well, it’s a human rights issue. It’s absolutely a human rights issue that we all have a right to healthcare whether we are trans, cis, or anyone. We all have an equal right to healthcare. And to think that we can differentiate people based on their gender is just outright discrimination. It’s appalling, and it’s worth the fight. It is absolutely worth the fight. When, as you say, when you see the benefits when you say it’s so starkly evident in front of you if you, something that is worth fighting for, and you feel that in your bones. I think, yeah, we’ve all got to keep up, keep up the fight for what’s right. But it does come at a personal cost.

Dr Helen Webberley:
But it’s the fact that having—Marianne, you were going to say something, sorry.

Marianne Oakes:
I have a question that came to my mind is the care in Australia, or at least in Melbourne, is that funded by the state or is it insurance based?

Dr Michelle Telfer:
Yeah, so we’re very fortunate in Australia that we have universal healthcare. So, it’s very similar to the NHS. We have Medicare. And for, for young people across Australia, there are a number of state-funded agenda services that will provide all care based under Medicare. So, it will be for free. And that doesn’t include any surgical care, but in terms of the mental health care, the medical care and the cost of puberty suppression, the state does provide that.

Marianne Oakes:
The reason I asked the question is that I’m not sure whether I’ve observed right, I think in countries where the state’s not necessarily funding it, the backlash from the media tends to be less than where—you know, all we get in the UK is, you know, this is taxpayer’s money, we’ve got a right, you know, to influence this. And I think that’s probably holding people back. You know, once, once we’ve got a social movement against what you’re trying to do, then it holds progression back. I was just wondering whether that’s the same in Australia, but it doesn’t sound like it is at the moment.

Dr Michelle Telfer:
No, well, we’ve got a very progressive government in Victoria. So, the Victorian government, which is the state that Melbourne is the capital of, our government is extremely progressive and has been the greatest supporter of the RCH gender service. This particular government that’s still in power now gave us the first big grant of $6 million over four years just to expand the team to cope with the rising demand. And we’ve just had our federal health minister also endorse gender-affirming health care across the country. And the federal health minister, Minister Hunt is, is still within the conservative government, but he has been able to look at the evidence, be advised on the evidence and has made a statement just in the last fortnight about the benefits of gender-affirming care. And he has made two particular recommendations.one being that care should be accessible equally across the country and that we need further funding for research to improve outcomes for transgender and diverse young people. So, I think we’re very fortunate with governments who, who will listen to experts and will make decisions based on evidence and what we’ve seen overseas, I guess where things are difficult. So even where care isn’t necessarily state-funded in the US, there are really strong anti-trans movements there too. So, yeah, I think there are lots of factors. We just feel very fortunate in Australia that we’ve got supportive governments who recognize the need for supporting these young people in a way that has the best outcomes.

Dr Helen Webberley:
Yeah. That’s amazing. You know, I think that’s, yeah, that’s, that’s, that’s a very, very positive help and support for you which is lovely. What was I going to say? I can’t remember what I was going to say, Marianne, were you going to say anything?

Marianne Oakes:
Well, I feel like I’m bombarding you with questions here, Michelle, so I apologize. I actually you’ve said these 350 referrals to you, was it last year?

Dr Michelle Telfer:
Yes, 2019.

Marianne Oakes:
Is that just in the state of Victoria then?

Dr Michelle Telfer:
Yes. That’s just in the state of Victoria.

Marianne Oakes:
Yeah. So, so I’m just trying to get at wonder what the magnitude of that is, you know, per population. But I would imagine it’s quite a lot that actually considering the numbers were given for the whole country in the UK, which is obviously far greater populated. That still sounds like a lot.

Dr Michelle Telfer:
Yeah. I’m not sure I’m going to get these numbers totally correct off the top of my head, but there have been two case studies done in one in New Zealand and one in Australia looking at the prevalence of young people who identify as trans and gender diverse, that the one from Australia was, was done only in the last year or 18 months, perhaps. And it was a secondary school survey looking at young people in mid to late adolescence. And 2.3% identified as trans or gender diverse, which is consistent with the New Zealand study, which also had about 6,000 secondary school students taken from across New Zealand. So, a good representative, large sample, and they showed that there was a 1.2% identified as transgender and 2.5% said they were unsure of their gender identity, and another percentage didn’t understand the question. So, if you think about trans and gender diverse young people as a, as a whole, it’s probably sitting around 2.3, 2.5%. We still have lots of barriers to accessing care in Australia that relate to socioeconomic disadvantage. Those that are in rural and regional areas where they don’t necessarily have the same supports and certain groups that are culturally and linguistically diverse who also probably found it much more difficult to access care for concerns about their gender. So, I don’t think our numbers yet reflect the actual population, but what we know that that with increasing societal acceptance and visibility and education around diversity and improving in areas of the human rights aspect of care generally, that the numbers will continue to increase until they get to a point where we can be confident that those that are needing care actually accessing that care.

Dr Helen Webberley:
Your general practice, primary care, whatever you will term you use in Australia. Because part of the big work that we do is trying to educate and empower primary care doctors and nurses and any anyone in that team to help young people and older people because we have a very, very much super, super-specialist tier system here, which clearly is not coping with that increase in numbers. And so, the waiting lists are huge, absolutely huge. And the damage that happens in that time you know, it’s hideous. Opportunities missed galore. So, a lot of our work is trying to empower primary care to take these steps, you know, and the first time you prescribed a puberty blocker for a young person, it’s quite scary, you know, there’s no doubt about it. It’s scary. But then when you see the benefit of that, it’s amazing. So, what’s it like where you are, you know, is extending out into primary care now or not yet?

Dr Michelle Telfer:
Yeah, that’s a good question. So, my feeling is that we really do need to expand into primary care for services to be sustainable. There’s no doubt about that and what, how we’ve gone about it so far is that we do have the belief that having a multidisciplinary care model is best practice. And there are opportunities to combine general practitioners in primary care with psychologists and other mental health specialists to work together to provide good care and not diminishing the expertise of general practitioners in providing mental healthcare, but what we find in Australia is the way things are funded, but general practitioners don’t often have enough time to provide the input that young people might need with their families around some of these decisions. So, what we’ve been doing, because we’ve been fortunate with our funding, up until recently when we have had things been under control in terms of waiting lists when we’ve had a young person who’s is council us receiving care from us we’ve brought the GP into that care as a shared care type arrangement. So, for example, if I have a young person on testosterone injections every three months. They might have one injection that the GP and a follow-up review with the GP and then see me only every six months, and that way we’ve been able to not only upskill GPs but also to educate more broadly with the practice there. So, getting people comfortable, like nursing staff and that practice providing injections, for example. They may have a psychologist within that practice they think the young person may also see if they need some extra support, especially the young people that have depression, anxiety, or other related difficulties. So, we’ve gone about things with shared care arrangement, but I think you right. It is real anxiety promoting towards GPs generally or primary care physicians. We tend to call them general practitioners here. But also, I think it’s going to take some time because none of us was taught much about providing care for trans and gender diverse young people when you’re at university. And medical students now are just starting to get the education. Probably they aren’t really getting enough education to feel comfortable to be able to do this when they become doctors working in the community. So, we need to approach it at different levels, and all work together. But the expansion of services into primary care really will have to happen over time to ensure sustainability. I’m not sure how the UK has managed the demand in adult services. Probably you can give me detail on that, but we know in Australia there has been expansion into primary care and there are a number of special primary care practices, three in particular that predominantly provide care for the trans community. And that’s been working really well. One particular speciality practice, known as Equinox, and that were set up by the trans community for the trans community, and it’s mostly bulk bill through Medicare. They have mental health clinicians. They have general practitioners. They (unclear 49:17) and others assisting in providing care for our population and that’s working really well. And I suspect that that will be the direction of things going generally.

Dr Helen Webberley:
I think in the UK, I mean in 2016 our women and qualities government body did a report and they really dug deep to find out what the trans experience was in the UK, and I think it obviously uncovered some shocking truths. And I think it’s fair, isn’t it Michelle, I think when you’re not educated in something, and you don’t know anything about it, and then you asked us to be an expert because doctors are experts in people’s health and so you’re asked to be an expert in something that you have no training, no education and maybe some personal belief about, and then you ask to help, and it’s that’s scary. And so, you’ve got the two things you can do. You can just back down, say I’m not looking I’m not touching absolutely no, no, no. Or you can go actually, well, let me read about it. I don’t think we have the support in the UK that you have been describing not some government or from our regulatory bodies. And actually, if Google what happens to doctors who help trans people in the UK, it’s not been a good history. So it’s not surprising for me that doctors are scared and are taking the opposite approach, which is no way am I going to dip my toe in this, I’m going to keep myself safe. But the problem is that that means that all those trans patients are not safe and that’s really sad. And I think the other thing that’s probably happening is that the doctors who are feeling comfortable enough to do something are not speaking about it for fear of being in some way told off, or you know you shouldn’t be doing that, you are not qualified to do that. So maybe there actually working in a quite isolated way and not supported because they’re not really coming forward and bravely say I’m doing this. So, you know, we’ve got a lot of work to do in the UK, I think, to move forward. And it also means that there are no guidelines, you know. I don’t know whether you know, we have NICE, which is the National Institute of Clinical Excellence in the UK, which governs a lot of what we do. And I wrote to them last year and said you know what was what have you got in the pipeline for transgender health, and they said sorry nothing. So it feels like we haven’t even started to create our own guidelines. You know, in the UK, from my point of view, has always been a forward-thinking nation. You know, we were up there. And it just feels in this particular field of healthcare, of society, of life that we’re very backward. And I am quite ashamed of that really. we’ve been working on some guidelines actually for GPs and not necessarily how to treat somebody not really medical, but just am I allowed to? You know if someone if an adult comes to me and says please can you give me some oestrogen instead of this horrible testosterone I’ve got, would that be okay? And it’s just like am I allowed to do that as a doctor? So we’ve been working on that. And I think the other thing for us going back to the use, is that the waiting time here is at least two years, and not from when you get to your GP, cause often when you go to your GP, there’s a delay in persuading your GP that you need a referral. And then when you do get referred, you have to wait at least two years to start the assessment process as a young person in the UK. And if in that time you teeter towards 17, you are moved on to adult services without even starting. So if you, if you’re going to GP at 14 and a half say, and kind of battling until 15, and then you’re not going to get any care at all until you’re 20 kind of thing. And we all know what’s the benefit stopping puberty, just putting puberty on hold, can kind of do. And Marianne, this goes a little bit back to what you were saying earlier, isn’t it, you know, if we can just press pause on puberty and give these kids a minute without that testosterone or oestrogen raiding through and causing those changes just a minute. And I feel personally as a GP, that that is well within the realms of the capability of the GP. And it would make such a difference to so many people in the UK. So for me, it’s about education and about permission, which is why I’m fighting this battle, my personal regulatory battle, right to the end. And I think that when—I don’t know, COVID’s come in and upset timings—but I was hoping that it would be complete this year, but I’m guessing that wouldn’t be complete till next year. And if that’s not successful, then we will go to the high court and the Supreme court, because it’s a really, you know, this permission as a doctor, are you allowed to provide care for trans people of all ages? And I think the answer should a hundred per cent be yes, and that’s why, you know, we’ll carry on with this battle. So yes, for me, it’s about education and, and permission. And that’s key. I’m encouraged to hear that in your medical schools and that education is starting. I hope so too. We have a medical student on our team who’s a real flag flyer and, you know, she’s been writing and educating in her medical school. And so I’m hoping that the future will be better for education.

Dr Michelle Telfer:
We have a number of groups within the university that I work within. So I have an appointment with the University of Melbourne. And they’ve held lectures for medical students for quite a number of years now. And the medical students themselves often opt to come and be attached to our unit so that they get some hands-on experience. It’s been fantastic just to see the enthusiasm there. And I can see that with time, we will eventually get to that point. But having situations like yours, Helen, where people see clinicians being targeted, whether it’s through colleagues or whether it’s in the press, you can see why people become afraid and why they might be reluctant to get into what is a very, very rewarding area of medicine. And the other thing about when we were going through medical school and, and even now, I, you know, certainly in my younger years learning to be a doctor, there’s an expectation that you are in control, but that you are an expert, that you have the answers. And for doctors to go into an area where they might not initially be comfortable, that they don’t know the answers, there’s a need to seek a certain level of uncertainty. I think that’s with adolescent medicine, generally, not just in this area, but in many areas of adolescent medicine, we have to sit with uncertainty. And they’re skills that need time to be developed. And really one needs to be well-supported to go into an area that that is new and is complex. Sorry, I agree with everything he said there.

Marianne Oakes:
I was just going to kind of umbrella everything that I’m hearing. Obviously, two clinicians talking, I think being a member of the trans community, what I see is there’s a social shift going on. And I think what’s happened to you, Helen, and please tell me if I’m wrong, but I think we’re caught up in a crossfire between evidence-based medicine and how the public feels about it. And I think that unfortunately is filtering through into the politics and filters then to the medical authorities. And that makes everybody nervous then. So if you’ve got a doctor that is exploring a new area of medicine, and everybody else is going, “Ooh, are you sure?”, it’s kind of, they’re going to filter through, you know, everything in society. So I think it’s balancing, you know, no education around gender diversity within schools, isn’t helping, you know, it should have started 40 years ago. This isn’t you, but it’s not even starting now. And I think that’s the battle that the trans community is facing. That we’re now hitting the obstacles that we should have been hitting over the last 40 years, but they’ve all come together if that makes sense.

Dr Helen Webberley:
Yeah, it has. And also, I think what you were talking about, the way that society has its and that filters into the powers that be, excuse me, what’s missing is the voices that Michelle has put into the Standards of Care. And that’s the voices of the young people, the voices of the trans community because they taught me everything. They taught me, absolutely everything I know. And then I backed that knowledge up with reading medical science. That was the bit that I can do because I’m medically trained. And I just sometimes just wanted to parade, you know, a bunch of trans youth in front of these people who are making decisions at such a high level about what happens to them and say, look at these youngsters, look how happy and successful they are now because they’ve had gender-affirming care. And then if you want to, have a look at those ones that have been denied it, and look at the difference and tell me that it doesn’t make a difference to provide the care that’s needed. So, yes, I’m passionate about that.

Dr Michelle Telfer:
One of the things that you said, Marianne, was about the public’s view on this is. My feeling in Australia is that the vast majority of people understand diversity and are accepting of diversity. And that the pushback that we’ve seen in terms of supporting trans young people is really driven by what is likely to be a, a smaller, a much, much smaller group. But they’re powerful. And they’re loud. And they have access to ways of amplifying their views, whether it’s through certain aspects of the press and media outlets. But the response that I get within Melbourne and Victoria, and more broadly, generally, is really supportive of trans youth. And I think it’s about continuing on with doing what’s right. Continuing on despite some of that negativity that is not based on the evidence. It’s not based on any formed view, and continuing to, to help what are a really vulnerable population.

Marianne Oakes:
I agree entirely, I think even in the UK, I talk about two different things. What I read in the newspapers and what I feel on the streets. And it couldn’t be more different. I’m not going to kid myself that, you know, there isn’t an element of tension depending on where I am, where I am. But you know, I go out and about, I buy my coffee, you know, sit in the cafes and go into the shops, and nobody’s ever stopped me. Nobody’s hesitated. So what I experience and what I read in the paper, you know, they’re a world apart. But I think the trouble is the more it’s fed into the paper, then it makes more trans people nervous that the visibility becomes a little bit less. And then, what we start getting into mental health issues, cause people are repressing. And then what we start saying, “Oh, well the trans people are all crazy.” You know what I mean,? That’s because we’ve created an environment, but no, I think you’re right. I don’t think it’s whether people are accepting of diversity. I think people just think, live and let live. I might not understand it, but you know, I don’t know this person, why have I got a problem with them? But that small group are the ones that are getting all the attention.

Dr Helen Webberley:
Well, thank you for joining us today, Michelle, it’s been really lovely to talk to someone, from so far across the world, but in a similar field to mine. It’s lovely, lovely to talk to you. Cause it’s hard to—I think there are so few clinicians working in this field and in such an affirming away, that’s what it feels like to me anyway. But it’s been really, really lovely to talk to you. And thank you for sharing, you know, the development of the Australian Standards of Care. We are so glad that you did that. So even if you thought it was just going to be for local use only, it definitely isn’t, it’s an amazing document. And thank you. And all the people that contributed to that for helping give us that permission in an evidence-based way, and also understanding that the evidence, okay, we have plenty of evidence. So there are so many people saying we don’t, we do have plenty of evidence, but it’s bringing as well, that personal case report into it as well, which is really vital. So thank you for doing that and thank you for joining us today and listening. I’ve enjoyed it.

Dr Michelle Telfer:
Thank you for having me on your program, Helen, and nice to meet you, Marianne.

Marianne Oakes:
Likewise.

Dr Helen Webberley:
Thanks very much. Bye.

Marianne Oakes:
Bye.

Dr Michelle Telfer:
Bye.

 

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