GPs trained to prescribe hormones to trans teens thanks to government funding

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Victorian government funding is underwriting an expansion in the number of GPs being trained to prescribe hormones to transgender people from the age of 16 as the state’s two specialist in-hospital clinics are seeing a drop-off in referrals for the first time in a decade.

Since 2019, health provider Your Community Health has trained 1790 health professionals, including 152 GPs, in providing the “affirming care” model of treatment, by which people born male can be given female hormones and people born female are given male hormones to help them change gender.

Some GPs are being trained to prescribe hormone treatment medication to trans teens.

Your Community Health chief executive Kent Burgess said his service was “the funded provider to try to increase access [to gender-affirming care] across the state”. They worked under an “informed consent” model that holds that people aged 16 and over, “do not require mental health sign-off from a trained psychiatrist [before treatment commences] unless there are particular indicators”.

The expansion of private and community transgender care comes as the number of new referrals to the main clinic for children at the Royal Children’s Hospital has fallen sharply in the previous two years after a decade of rapid growth. The clinic treats children aged eight to 16, and it’s the first time since 2011 that new referrals have declined. There were 820 referrals in 2021 but only 634 in 2022.

State government figures also show new referrals at Monash Health’s gender clinic, which treats people aged 16 and over, peaked in 2021 at 641 but dropped to 537 in 2022.

It’s unclear why the numbers have declined, but a number of experts and trans community advocates The Age spoke to speculated that it might be because people were finding alternatives to a system that has become known for long waiting lists and tight controls.

The hospital clinics say in documentation that young people seeking treatment are seen by a multidisciplinary team of doctors, psychologists and psychiatrists before treatment can be approved. Outside hospitals, under the “informed consent” model, people can be assessed and approved for treatment more quickly.

Nationally, figures for hospital-based gender clinics are more mixed, with referrals to Western Australia’s clinic declining since a peak in 2021, while South Australia’s referrals have continued increasing. The gender clinics in NSW and Queensland did not supply sufficient data to make comparisons.

The Victorian government and both the state’s publicly funded hospital clinics declined to explain the figures. Two months after The Age was promised a number of other key statistics, including how many referrals to the gender clinics proceeded to medical treatment, how many young people were put on puberty-delaying drugs called “puberty blockers”, and how many then proceeded to hormone therapy, the government refused to answer, citing privacy considerations.

No figures are available for how many people are being treated in doctors’ clinics because no separate Medicare number exists for cross-gender treatment.

The 2022-23 state budget put $21 million over four years into expanding the children’s hospital and Monash gender services, as well as funding advocacy and service organisations Transcend Australia and Transgender Victoria.

It also allocated $1.5 million to the community health program described by Burgess, which includes two community clinics (in northern Melbourne and Ballarat), and the health practitioner training programs. In March, the government delivered another $900,000 to eight organisations.

The state government said in a statement that it “is dedicated to improving the lives of all LGBTIQ+ Victorians and is proud to fund a range of programs that support trans and gender diverse communities”.

Your Community Health’s Burgess said treatment at GP clinics was expanding “because the LGBTI community sector and the state government saw that there was an enormous demand for gender-affirming services for Victoria and … this is something that should be available in standard general practice”.

Training GPs to provide these services had removed an enormous barrier, Burgess said. The new community practitioners and a network of GPs had made “enormous inroads into making gender-affirming care available in Victoria through the primary care setting”.

“Peer navigators” – transgender people employed to help young people find their way through the system – had also made the system more efficient, Burgess said. However, a challenge remained that not many GPs were prepared to prescribe hormones to children under 16, and “access is still very, very low in that cohort”, he said.

This was partly because of medico-legal and potential insurance issues, he said. Among these was the recent refusal of a key insurer for GPs, MDA National, to provide indemnity insurance for those treating under-18s because they could not “accurately and fairly price the risk of regret”.

Burgess said the aim of the state government’s programs was to treat more people “earlier in the primary care system rather than having to wait for tertiary care, and not subject individuals and families in community to unnecessary barriers that we know through good evidence don’t lead to better outcomes”.

Melbourne clinical psychologist Ben Callegari said he delivers affirming care to people over 16. He said the people he sees have generally done a lot of research, are well-informed about the options, and have “a deep sense of knowing” that they are transgender.

He provides them with the pros and cons, as well as the risks. “So with hormones, we talk about what they do; benefits, risks, what’s permanent and not permanent,” he said, adding it’s within a “very affirming” approach. Callegari said he is now seeing more people who are non-binary than those attached to stricter notions of gender.

It was important not to be alarmist at the rising number of children coming out as trans or gender diverse, he said.

“So what if your child comes out … why is that problem? The hysteria implies it’s a negative and they don’t want their child to be like that,” he said. “Deeply rooted in the idea is that transgender is not real. If you speak to a trans person, they know. It’s a deep sense of knowing. Like talking to a gay person, how do you know? I just know.”

He said there were risks in not transitioning, which are not spoken about.

Patrick Parkinson, an emeritus professor of law at the University of Queensland, said there were doubts about the legality of the informed consent treatment.

The Family Court has held that it does not need to become involved in the matter if there has been a mental health diagnosis of gender dysphoria and both parents and clinicians consent to treatment. However, Parkinson, who spoke via video link at a recent forum in parliament with a number of doctors and lawyers lobbying for an upper house inquiry into affirming care for teens, said that ruling was “based on people being treated by a multidisciplinary team in a hospital setting”.

He said he had doubts about the legality of GPs “prescribing hormones [to 16- and 17-year-olds] without a formal diagnosis of gender dysphoria and the involvement of an expert multidisciplinary team”. The court had also “never approved the use of these drugs” for non-binary or gender diverse people, he added.

Parkinson said he knew of a number of challenges to gender-affirming care in the Family Court, details of which cannot be discussed because of the court’s strict secrecy protocols, and he expected more.

The co-chair of the Royal Children’s Hospital clinic, Cate Rayner, said in a podcast in 2022 that it was “a myth that you can walk into the hospital’s clinic and walk out with hormones”.

“They wait years to come to the clinic, then wait again. It’s a real commitment … to get here, to get through the process.”

“I think if we listen to our young people they’ll often show us what they need,” she said.

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