Hormone treatment of gender identity disorder in a cohort of children and adolescents

In reply: We thank Hyde and Conway and colleagues for their correspondence following our report on treatment for young people with gender identity disorder (GID).1 We follow current international consensus recommendations for management,2,3 but accept that as more research is performed, there may be future adjustments to endorsed protocols. At present, patients can apply to the Family Court of Australia for authorisation of treatment that varies from current guidelines, such as commencement of cross-sex hormone therapy before the age of 16 years.1

The assertion that earlier cross-sex hormone treatment may increase final height is incorrect. Puberty leads to growth plate fusion, so although earlier hormonal suppression of puberty (phase 1) may increase final height, earlier treatment with cross-sex hormones (phase 2) may in fact reduce final height.

In New South Wales and South Australia, Special Medical Procedure legislation only applies to those aged under 16 years; however, the Family Court of Australia is a national body whose judgments are both constitutionally overriding and apply to children aged under 18 years.4 As far as we are aware, no definitive decision has been made by the court deeming a child under 18 years to be Gillick competent to consent to GID treatment; that is, assessed as having sufficient understanding, intelligence and maturity to be able to provide independent informed consent to the proposed treatment.4 In view of inconsistent national practice, it is urgent that legal bodies clarify whether a mature minor can consent to treatment leading to gender reassignment, or if Family Court authorisation is required in all cases. Further, Gillick competence is a variable and graduated concept, and the question of how it should be assessed requires specific consideration. We firmly agree that application to the Family Court is a very difficult process in specialised areas of paediatric medicine — for this reason, some have called for a specific tribunal to be established, while others have challenged the need for court involvement entirely.4,5

Suppression of puberty and the use of cross-sex hormones in an adolescent are extremely serious undertakings, requiring rigorous protocol and care. Some patients travel interstate for treatment and, unfortunately, may need to continue to do so until there are more services available. It is difficult to find clinicians willing to provide care for this group of patients, and like the corresponding authors, we advocate support for those who do.