Probe into trans teen autism rate

Health ministers in charge of children’s hospital gender clinics told to investigate overrepresentation of autistic teenagers

Since the 2000s there has been a puzzling surge in teenagers, chiefly girls, seeking medical treatment for distress over “being born in the wrong body”.

Health ministers in charge of children’s hospital transgender clinics across Australia should take responsibility for investigating the overrepresentation of teenage patients with autism, according to federal Health Minister Greg Hunt.

Mr Hunt’s intervention follows reports in The Australian that a leading authority on Asperger’s syndrome, Tony Attwood, wants an inquiry into the autism trend, and revelations that the country’s biggest gender clinic at the Royal Children’s Hospital in Melbourne had 45 per cent of a group of chiefly female-born teenagers showing autism features on a screening test.

Mr Hunt said he would also ask state and territory health ministers to examine new, more cautious treatment advice and warnings adopted by Britain’s National Health System for trans-identifying under-18s and parents deciding on life-altering medical interventions.

There is international concern about the safety and ethics of medicalisation of vulnerable children and teens who do not fit gender stereotypes.

The Australian Health Ministers’ Advisory Council, which brings together top health officials, is due to discuss on June 24 a review into youth gender clinic treatments referred by Mr Hunt.

The federal minister stressed the need for “strong and balanced counselling and safeguards” and tracking of “long term health and wellbeing outcomes” by state and territory health bodies.

His spokesman said Mr Hunt would “specifically refer the questions of overrepresentation of teens with autism and changes to the UK guidelines to state and territory ministers” running children’s hospital gender clinics.

Good to see @LaTrioli pick up my news report on the striking overepresentation of teens with #autism in gender clinics | Trioli says it's an issue that "repays further attention" I | She talks with Tony Attwood from 1:09 mark https://t.co/ICv1UVYQ1f @abcnews #childwelfare

— Bernard Lane (@Bernard_Lane) June 7, 2020

Drugs to block unwanted puberty, starting as young as 10, have been promoted as a safe and reversible way to give children a breathing space before deciding to go on to irreversible opposite-sex hormones around age 16, but studies suggest almost all stay on the medical path.

Advocates say blockers are “life-saving” but critics protest the evidence for their mental health benefits is short-term, low-quality or flawed.

Meanwhile, an unreported paper raises “ethical dilemmas” in the case of a 15-year-old RCH “non-binary” patient known as EF, who was born a boy but does not identify as male or female, uses the pronoun “they”, and wants to stay “long-term” on puberty blockers, with a risk of osteoporosis.

“Their bone mineral density has regularly fallen (as a result of the blocker drugs) and is now in the lowest 2.5 percentile, although there have been no fractures,” says the article in the journal Paediatrics authored by RCH doctors Ken Pang and Michelle Telfer together with bioethics experts.

“EF, whose desire for biological children in the future remains unclear (hormone treatment can lead to sterility), wishes to continue puberty suppression until they are at least 18.”

The paper concludes an “attractive” solution is to supplement the blockers with another hormone drug class known as SERMs which “could theoretically promote improved bone density while preventing the development of unwanted secondary sexual characteristics”.

But the experts admit the two drugs have never been used together with a young patient, and SERMs given to adults for other conditions are linked to hot flashes, blood clots and cognitive impairment, the latter a risk that could be “exacerbated in the developing adolescent brain”.

Endocrinologist Will Malone, from the US-based watchdog the Society for Evidence-Based Gender Medicine, said “giving a SERM to a child is more of the same — as (Oxford University professor of evidence-based medicine) Carl Heneghan has remarked, medical intervention in children with gender dysphoria is an unregulated live experiment”.

RCH refused to comment. In December, it said the gender service followed “strict clinical governance standards”.

The British NHS, which runs the Tavistock youth gender clinic in London, used to claim puberty blocking was “fully reversible” but quietly updated its advice a fortnight ago, warning “the psychological effects” of these drugs are unknown.

“It’s also not known whether hormone blockers affect the development of the teenage brain,” says the NHS web page on treatment for gender dysphoria (or distress at being born in the wrong body).

“Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.”

The NHS now distances itself from the claim that puberty blockers are “a physically reversible treatment”, sheeting this statement home to the Tavistock clinic itself. The NHS is reviewing the safety of hormone treatment and is fighting a court claim that under-18s cannot give informed consent to treatments with long-term effects unknown to experts.

Senior NHS endocrinologist Gary Butler, a professor at University College London, has said a young person on blocker drugs “remains in a state of arrested puberty and also most probably with a form of arrested emotional development”.

Dr Telfer, the paediatrician who runs the RCH clinic — where referrals have increased 1,767 per cent since 2012, reaching 336 new patients last year — was quoted by GQ magazine in 2015 as saying these drugs “don’t stop growth generally, or your brain from maturing emotionally and cognitively, they just stop the sexual characteristics from developing”.

The Telfer clinic’s 2018 treatment guidelines, promoted as “Australian standards” but not measuring up to the National Health and Medical Research Council’s “gold standard” for approved national guidelines, claim “reversible” puberty blocking gives young people time to mature before committing to irreversible opposite-sex hormones.

The Children’s Hospital at Westmead in Sydney says the only medical treatment it offers is “completely reversible” puberty blocking. Its new referrals have almost doubled, reaching 90 last year.

The Queensland Children’s Hospital gender clinic — where last year’s total caseload of 611 patients represented a 1,172 per cent increase since 2014 — says puberty blockers “pause” aspects of puberty, such as “chest growth”.

Psychologist “Megan”, not her real name, whose 15-year-old daughter with Asperger’s went to the clinic, said they were told blockers were safe and could be stopped at any time.

“What they never said was that puberty blockers could set teens on a psychological trajectory to medical transition,” she said.

“They never seemed to consider that once blockers are started, teens go online to discuss their experiences — and seeing other teens’ experiences on cross-sex hormones, they are often chafing at the bit to get to the next phase of their medical transition.

“How easy is it for a vulnerable, naive teenager to halt her transition — to admit to herself, I was wrong, this is not what I want, I am not really trans and then lose the online — and sometimes real-life — community where she felt some sense of belonging?”

Brown University researcher and physician Lisa Littman said it was not yet known if blockers made it less likely that today’s teenage-onset patients would grow out of gender dysphoria, as was the case for more than 60 per cent of an earlier generation of preschool-onset patients.

“The possibility that puberty blockers might change a child’s developmental trajectory is information that is vital to the process of informed medical decision-making,” Dr Littman told The Australian.

Advice to Mr Hunt from the Royal Australasian College of Physicians, which claimed a national inquiry would be “dangerous”, did not mention the autism issue or compare the gender clinic medical treatments with more cautious psychological approaches.

The Australian put questions about autism in gender clinics to all state and territory health ministers.

Queensland Health said its care was “guided by” the RCH treatment standards, although a public document notes the Brisbane gender clinic has a stricter checklist before giving puberty blockers.

NSW Health said patients were assessed according to “accepted guidelines” for gender dysphoria and referred to relevant clinicians if “any medical conditions” were picked up.

No other jurisdiction replied.